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When to Treat Osteoporosis
Alan Jacobs M.D.
Arthritis Center of NebraskaLincoln, Nebraska
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We are like twigsbut green is better than brown
calculate how green you are
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Treatment Concerns
Too many young people are being treated who are not at animmediate risk of a fracture
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Treatment Concerns
Too many young people are being treated who are not at animmediate risk of a fracture
Long-term complications of treatmento ONJ - osteonecrosis of jawo "frozen bone" adynamic fractureo eye inflammation
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Treatment Concerns
Too many young people are being treated who are not at animmediate risk of a fracture
Long-term complications of treatmento ONJ - osteonecrosis of jawo "frozen bone" adynamic fractureo atrial fibrillationo eye inflammation
Too much emphasis on BMD
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Treatment Concerns
Too many young people are being treated who are not at animmediate risk of a fracture
Long-term complications of treatmento ONJ - osteonecrosis of jawo "frozen bone" adynamic fractureo atrial fibrillationo eye inflammation
Too much emphasis on BMD T-score misinterpretations
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Risk - predicting the future
"Relative risk" - old method in osteoporosis predictiono "It is twice as likely to rain today than 1 year ago"
"Absolute risk" - new method with FRAXo "There is an 80% chance of rain today"
We finally have a useful tool!
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Calculate an absolute risk with
FRAX
WHO Fracture Assessment Tool
http://www.shef.ac.uk/FRAX/index.htm
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FRAX - fracture risk over 10 years
WHO project - NOF, IOF endorsed Web based calculation compilation of fracture studies and risk factors applies to men and women above 40 varies according to the country and race
BMD is not needed treatment suggestions based on FRAX vary according to country
and cost of medication
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FRAX risk factors
age ht/weight parental hip fracture rheumatoid arthritis
glucocorticosteroid use
explained on Web site
past fractures smoking alcohol use secondary osteoporosis
femoral neck T-score
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Treatment guidelines
"Cost-effective" for standard treatments if:o greater than 20% Major Fracture 10 year risko or greater than 3% Hip Fracture 10 year risk
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T-score conversion
FRAX patch utility - http://www.nof.org/frax_patch_full.htm
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What FRAX does
reduces treatment for younger people increases treatment for older people ability to discuss absolute risk with the patient
Does not address prevention of bone loss other risk factors BMD in other sites
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Vertebral fracture detection
criteria for treatment 2/3 fractures are asymptomatic often neglected plain x-rays ok but VFA better
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VFA - vertebral fracture analysis
from T4 to L4 manually determine the borders minimal x-ray exposure
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VFA or IVA
vertebral fracture analysis computer evaluation of the rectangular shape of the vertebra with
comparisons to the adjacent ones useful for subtle fracture detection and serial comparisons
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Results of VFA
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When to Treat Osteoporosis ?
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NOF Treatment Guidelines - 2008
Women and men over age 50:
1. A vertebral or hip fracture
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NOF Treatment Guidelines - 2008
Women and men over age 50:
1. A vertebral or hip fracture
2. Low bone mass and a US-adapted WHO 10-year probability of ahip fracture 3% or 10-year probability of any major osteoporosis-
related fracture 20%
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NOF Treatment Guidelines - 2008
Women and men over age 50:
1. A vertebral or hip fracture
2. Low bone mass and a US-adapted WHO 10-year probability of ahip fracture 3% or 10-year probability of any major osteoporosis-
related fracture 20%
3. A DXA hip (femoral neck) or spine T-score -2.5
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NOF Treatment Guidelines - 2008
Women and men over age 50:
1. A vertebral or hip fracture
2. Low bone mass and a US-adapted WHO 10-year probability of ahip fracture 3% or 10-year probability of any major osteoporosis-
related fracture 20%
3. A DXA hip (femoral neck) or spine T-score -2.54. Patient preferences may indicate treatment for people with 10-year
fracture probabilities above or below these levels
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Review the slides
http://alan.jacobs.googlepages.com/FRAXor
http://tinyurl.com/treatingosteoporosis
URL of FRAX
http://www.shef.ac.uk/FRAX/index.htm
Patient Video
http://www.nebraskaarthritis.com/resources.htm