Osteoporosis 2016 | Fracture Risk assessment tools: Prof. Eugene McCloskey #osteo2016

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)

FRAX Version 3.11www.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


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


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

Impact of prior fracture in FRAX and QFracture

Female, no additional risk factors, BMI 25 kg/m2

• 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


Guidance is essential!

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

Hip fracture reduction by baseline hip fracture probability

Interaction p=0.021

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.