osteoporosis 2016 | fracture risk assessment tools: prof. eugene mccloskey #osteo2016
TRANSCRIPT
Fracture risk assessment toolsThe First (but not the last) Antony
Johansen Remedial Lecture
Eugene McCloskeyProfessor of Adult Bone DiseasesUniversity of SheffieldRecipient of the First (but not the last!) Antony Johansen/Donald Trump Joint Remedial Statistics Prize
The aims in managing osteoporosis
• TO REDUCE THE INCIDENCE OF FRACTURES• To identify patients at increased risk of fracture• To be able to assess that risk accurately• To give advice to aid understanding of the disease, the aims
of therapy and the choice of therapy• Treatment
• Lifestyle advice• Therapeutic agents
What is the intended use of fracture risk tools?Osteoporosis is a common disease
It should largely be managed in primary care.Experts in osteoporosis are used to integrating information
derived from multiple risk factors, but most primary care physicians in many countries have little expert
knowledge. It is this constituency for which fracture risk tools are primarily
designed To increase awareness and knowledge of osteoporosis and to
initiate appropriate treatment in patients at highest risk of fracture.
Risk factors for hip fracture in men and women
0.0
1.0
2.0
3.0
RR
Without BMD With BMD
Priorfracture
FH(hip)
Smokingcurrent
Alcohol 3u
Steroidsever
RA
Kanis JA on behalf of WHO Working Group, Technical Report 2008 (www.shef.ac.uk/FRAX)
Fracture risk assessment models QFracture FRAX
Externally validated Yes (UK only) Yes
Calibrated No YesApplicability UK 57 countriesFalls input Yes No
BMD input No Yes
Prior fracture input Yes Yes
Family history input Yes YesOutput Incidence ProbabilityTreatment response assessed No Yes
Thresholds/guidance No Yes
NICE SCG Fracture Risk Assessment• Consider assessment of fracture risk in in all women aged
65 years and over and all men aged 75 years and over .
• Consider fracture risk in women <65 years and men <75 years if they have any of the following risk factors:
• Do not routinely assess fracture risk in people <50 years unless major risk factors (e.g. GC use, untreated premature menopause, previous fragility fracture).
• previous fragility fracture• current or frequent use of oral
glucocorticoids• history of falls• family history of hip fracture
• causes of secondary osteoporosis• low BMI (<18.5 kg/m2)• smoking >10 cigarettes per day• alcohol intake > recommend units
Osteoporosis: fragility fracture risk: NICE guideline August 2012
• Use either FRAX (without a BMD value) or QFracture to calculate 10-year predicted absolute fracture risk when assessing risk of fracture.
• Do not routinely measure BMD to assess fracture risk without prior assessment using FRAX (without a BMD value) or QFracture.
Further NICE Recommendations
Osteoporosis: fragility fracture risk: NICE guideline August 2012
Risk factors in QFracture-2012/16
• Age • Sex • Ethnicity • Body mass index• Smoking status• Alcohol use • Use of corticosteroids• Parental history of hip
fracture/osteoporosis • Prior osteoporotic fracture (wrist,
spine, hip, or shoulder)• Rheumatoid arthritis or SLE
• History of falls • Dementia/Nursing or care home
residence • Type 1 or Type 2 diabetes • Cancer • Asthma or COPD • Cardiovascular disease • Chronic liver disease • Chronic kidney disease • Parkinson's disease • Gastrointestinal malabsorption • Epilepsy or use of anticonvulsants • Use of antidepressants• Endocrine problems (thyrotoxicosis,
hyperparathyroidism, Cushing’s)
http://qfracture.org; Hippisley-Cox & Copeland, BMJ 2012;344:e3427
• Use either FRAX (without a BMD value) or QFracture to calculate 10-year predicted absolute fracture risk when assessing risk of fracture in people of between 40 and 84 years.
• Do not routinely measure BMD to assess fracture risk without prior assessment using FRAX (without a BMD value) or QFracture.
NICE Recommendations
Osteoporosis: fragility fracture risk: NICE guideline August 2012
Absolute risk values are not the same
40 50 60 70 80 900
5
10
15
20
25
30
35
40
Qfracture-2012 (Major) Qfracture-2012 (Hip)FRAX (Major) FRAX (Hip)
Woman with prior fracture, BMI 24, no other CRFs
• Following risk assessment with FRAX (without a BMD value) or QFracture, consider measuring BMD with DXA in people whose fracture risk is in the region of an intervention threshold for a proposed treatment, and recalculate absolute risk using FRAX with the BMD value
• It is out of the scope of this guideline to recommend
intervention thresholds.o Healthcare professionals should follow local protocols or other
national guidelines for advice on intervention thresholds.
NICE RecommendationsBMD and Intervention Thresholds
Osteoporosis: fragility fracture risk: NICE guideline August 2012
Case Finding Strategies
CRFs
BMD
T-score< -2.5
Treat
RCP 1999
CRFs
FRAX
High
Treat
Intermediate Low
BMD
FRAX
High Low
Treat
National Osteoporosis Guideline Group 2008
Compston et al, Maturitas (2009); 62(2):105-8; www.shef.ac.uk/NOGG
www.shef.ac.uk/NOGG
0
10
20
30
40
50
40 45 50 55 60 65 70 75 80 85 900
10
20
30
40
50
40 45 50 55 60 65 70 75 80 85 90
10 year fracture probability (%)
Age (years)
Consider treatment
Measure BMD
No treatment
Consider treatment
No treatmentInterventio
n threshold
Age (years)
10 year probability of major osteoporotic fracture (%)
Compston et al, Maturitas (2009); 62(2):105-8; www.shef.ac.uk/NOGG
0
5
10
15
20
25
30
35
40
45
40 45 50 55 60 65 70 75 80 85 90Age (years)
10-year probability of major osteoporotic fracture (%)
Treat
Measure BMD
Lifestyle advice and reassure
Updated NOGG Assessment Thresholds
Coming in early 2017…….
Letter of invitation
Agree to take part
CONTROL SCREENING
Intermediate/High
DXA
Low RiskHigh Risk Unknown
Baseline Information
Randomisation
Low Risk
• Women aged 70-85 years, not on anti-osteoporotic medication identified from GP lists
• 7 geographical regions of the UK
• Randomly allocated to control (usual management) or intervention (screening).
• In those subjects deemed at high risk of hip fracture, family doctor advised to intervene.
• Follow-up for 5 years.
• Osteoporotic fracture as primary endpoint; hip fracture and mortality as secondary endpoints.
Including FRAX questionnaire
FRAX
FRAX
Hip fracture outcome
HR 0.72 (0.59, 0.89) P=0.002
Number needed to screen to prevent one hip fracture = 111
Stepwise implementation
Objective 1: Improve outcomes and improve efficiency of care after hip fractures – by following the 6 “Blue Book” standards
Hip fracture patients
Objective 2: Respond to the first fracture, prevent the second – through Fracture Liaison Services in acute and primary care
Non-hip fragility fracture patients
Objective 3: Early intervention to restore independence – through falls care pathway linking acute and urgent care services to secondary falls prevention
Individuals at high risk of 1st fragility fracture or other injurious falls
Objective 4: Prevent frailty, preserve bone health, reduce accidents – through preserving physical activity, healthy lifestyles and reducing environmental hazards
Older people
FRAX
DoH Falls and Fractures CommissioningTool Kit
Summary• NICE has endorsed the use of FRAX or QFracture in the
assessment of fracture risk.
• Clinical utility requires assessment thresholds, integration of BMD, intervention thresholds and demonstration of reversibility of risk.
• The SCOOP study demonstrates that a screening program based on FRAX significantly reduces hip fractures.