Bollheimer

MEDIZIN I UNIVERSITÄT REGENSBURG

Dept. of Internal Medicine I University of Regensburg

Dept. of Internal Medicine 2Klinikum Nürnberg

Germany

How To Assess The (Fracture) Risk

Of Primary Osteoporosis ?

4th International Seminar on Preventive Geriatrics1st International Seminar on Geriatric Rehabilitation

Osteoporosis »Prevention and treatment«Athens, 1st April 2011

Cornelius Bollheimer

KLINIKUM NÜRNBERG


Primary – age-related osteoporosis

Secondary types of osteoporosis:

Primary hyperparathyreodism

Hypercortisolism (endogenous / exogenous)

Long-standing (male) hypogonadism

Renal osteopathy / chronic kidney disease

Severe vitamin D deficiency / osteomalacia

Multiple myeloma

Diagnosis of (i.e. after!) exclusion

Filter (lab-values, patient‘s history …)

Primary Osteoporosis = Diagnosis Of Exclusion !

!


20 30 40 50 60 70 80 age

Individual A

Individual B

Individual C

Severity ofosteoporosis

Increasedfracture Risk

Indicationfor treatment

Arbitrary Threshold for osteoporosis

Bone mass & quality

Assessment Of Osteoporosis Impeding Fracture Risk


Closing In On A Theory Of Everything

as assessed by DXA

Bone mass

+Bone quality

as assessed by

clinicalsurrogate parameters + X =

Fracture riskof

osteoporosis

Severityof

osteoporosis=


Osteoporosis Handling 20 Years Ago

Fragilityfracture

[= 100% fracture risk]

1

Decreased bone mass

2

[ Antiresorptive or bone-forming drugs ]

Tertiaryprevention

3


Osteoporosis Handling 10 Years Ago

Normal distribution of the bone densityof 30-year old individuals (gender-specific)

-1-2,5

Osteoporosis

Osteopenia

bone mass[T-score]

Secondaryprevention

[ Antiresorptive or bone-forming drugs ]

2

Decreased bone mass

1

metrological definition


Surrogate Parameters Of Bone Quality

Bone mass +Bone quality

influenced by

age gender+ X = Fracture risk

of osteoporosis

4

8

12

16

20

-2,5 -1 0-2,5 -1 0

4

8

12

16

20

10-year hip fracture probability [%] 10-year hip fracture probability [%]

Age effect Gender effect

[T-score] [T-score]

80yrs

80yrs

+80yrs

+

50yrs

+

Kanis et al [2008] Osteoporos Int


DXA Is Not Affordable 2 Step Approach

Fracture risk

Comparison of the

individual results

with

epidemiological data

3

Bone quality

Refined list of

clinicalsurrogate parameters

1

Bone mass2

Bone density by DXA

If clinical suspicion is high, then:


FRAX = WHO Fracture Risk Assessment Tool

http://www.shef.ac.uk/FRAX

Clinical parameters associated with bone quality:

Low Body mass index

Previous low energy fractures

Parent hip fracture

Current smoking

Alcohol consumption

Use of glucocorticoids

Rheumatoid arthritis

Other types of secondary osteoporosis


The Lower The BMI, The Higher The Fracture Risk

Clinical parameters according FRAX :

Kanis et al [2008] Osteoporos Int // http://www.shef.ac.uk/FRAX

0,6

2,3

20 40

10-year hip fracture probability [%]

BMI-effect

BMI [kg/qm]

65yrs

+

Low Body mass index


Parent hip fracture

Current smoking

Alcohol consumption



Other types of sec. osteoporosis

!


Conditions Which Roughly Double The Fracture Risk

Clinical parameters according FRAX:

Kanis et al [2008] Osteoporos Int // http://www.shef.ac.uk/FRAX

Low Body mass index


Parent hip fracture

Current smoking

Alcohol consumption




… having occured spontaneously or

having arisen from a trauma which in a

health individual would not have resulted in a fracture

≥ 3 units per day, i.e. ≥ 750 ml beer

≥ half a bottle of wine

≥ 3 shots of


Oral Glucocorticoids And Rheumatoid Arthritis



Low Body mass index


Parent hip fracture

Current smoking

Alcohol consumption




≥ 5 mg prednisone for ≥ 3 months

now or in patient‘s history


The Most Labour-Intensive Topic Of FRAX



hyperthyroidism

type 1 diabetes

hypogonadism, premature menopause (< 45 yrs)

use of aromatase inhibitors in breast cancer

inflammatory bowel disease

organ transplantation

immobility

Low Body mass index


Parent hip fracture

Current smoking

Alcohol consumption



Other types of secondary osteoporosis


Population-Based Estimate Of The Individual Fracture Risk

10-year fracture probability

- for any major osteoporotic fracture

- for hip fractureselectively

Clinical risk factors

+/- DXA [femoral neck]

Low Body mass index ___ kg / qm

Previous low energy fractures yes ?

Parent hip fracture yes ?

Current smoking yes ?

Alcohol consumption yes ?

Use of glucocorticoids yes ?

Rheumatoid arthritis yes ?

Other secondary osteoporosis yes ?

T-score ___

Comparison with epidemiological data


0% 20% 30%

0% 3%

10 year risk of any major osteoporotic fracture [ i.e. spine, hip, shoulder, wrist ]

10 year risk of hip fracture

antiresorptive or bone forming agents ? No ! (Consider) Yes !

10-Year Fracture Risk - Handling Instructions

National Osteoporosis Foundation [2010] Clinician’s Guide to Prevention and Treatment of Osteoporosis // Compston J et al [2009] Maturitas


Only Health-Economical Reasons For The Thresholds ?

?

15 persons each with a 10-year-fracture risk of 30%

no additional treatmentwith antiosteoporotic drugs

# #

# # #

treatment for 5 yearswith antiosteoporotic drugs


The Fracture Risk Also Depends On Where You Live

Bone mass + Bone quality + X = Fracture riskof osteoporosis

3

9

10-year hip fracture probability [%]

70yrs

+6

70yrs

Kanis J et al [2002] JBMR 2002 17:1237 // Lippuner et al [2009] Osteoporos Int


European Index Countries

very high risk

high risk

moderate risk

Valid epidemiological dataaccording FRAX

© EU 1995-2011



Conclusions

Assessment of primary osteoporosis means assessment of its impeding fracture risk.

The DXA-test for bone mineral density is not sufficient and affordable to assess the fracture risk.

Clinical risk factors play a growing role in the assessment of osteoporosis. The most important algorithm is the so called FRAX-tool.

Based on this clinical information together with an optional DXA a calculation of the individual 10-year fracture risk is possible.

Evaluation of osteoporosis has become a computer-based risk assessment by comparison individual information with already existing epidemiological data.

1

2

3

4

5

Bollheimer

Health & Medicine

majorosteoporotic fracture

year hip fracture probability

osteoporosis handling

dxa bone mass

major osteoporotic fracture

clinical risk factors

bone densityby dxa

clinical surrogate parameters