Tufts University researcher Bess Dawson-Hughes, M.D., chaired the committee that recently updated the National Osteoporosis Foundation (NOF) Clinician's Guide to Prevention and Treatment of Osteoporosis. The new Clinician's Guide incorporates the World Health Organization (WHO) absolute fracture prediction algorithm (FRAX®), a computer-based tool expected to increase the identification of patients at risk for osteoporosis.
"The introduction of the WHO's fracture prediction algorithm necessitated the revision of the Clinician's Guide," says Dawson-Hughes, director of the Bone Metabolism Laboratory at the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University. "The algorithm tells clinicians how likely a patient is to fracture a bone due to osteoporosis or low bone mass in the 10 years following examination, also known as 10-year fracture risk. This can help clinicians decide whether a patient needs to be treated or simply monitored."
Writing in the April 2008 issue of the journal Osteoporosis International, corresponding author Dawson-Hughes and colleagues describe how to apply FRAX® in the United States. Clinicians estimate a patient's 10-year fracture risk using a computer program that considers bone mineral density (BMD) score, or T-score, and nine clinical risk factors including personal fracture history, family fracture history, weight, race and gender. Notably, FRAX® and the new Clinician's Guide now apply to men over 50 and post-menopausal non-Caucasian women, including African-Americans, Asians and Latinas. Previous versions applied only to post-menopausal Caucasian women, the group at highest-risk for osteoporosis.
In their analysis, Dawson-Hughes and colleagues highlight the inclusion of men in the guide. "Post menopausal women remain the most vulnerable to osteoporotic fractures, yet clinicians should not overlook men because their fracture risk may be lower," says Dawson-Hughes, who is also a professor at Tufts University School of Medicine. "The new U.S.-adapted FRAX® will help identify high-risk subgroups of men and non-Caucasian women and, we hope, a wider population of patients at risk for osteoporosis will be treated. Use of FRAX® in men and non-Caucasian women will require adjustments in their T-scores that currently appear on bone density reports. "
Additionally, FRAX® and the new Clinician's Guide address the cost-effectiveness of prescribing medication to patients with low bone mass, but not osteoporosis. Dawson-Hughes and colleagues performed an economic analysis that calls for treating patients with a 10-year hip fracture risk of 3 percent or greater or a major fracture risk of 20 percent or greater. That would include; patients with fragility fractures or osteoporosis, older patients at risk for osteoporosis and younger patients presenting additional clinical risk factors for fracture. FRAX® is applicable to men and women over age 50, but not to younger people.
"The ability to estimate 10-year fracture risk is a crucial development in osteoporosis care, but it is still important for clinicians to review patient cases on an individual basis," says Dawson-Hughes. "Ten-year fracture risk should be used as a guideline."
The following are some recommendations from the new Clinician's Guide:
- BMD testing for women age 65 and older and men age 70 and older and in post-menopausal women age 50-70 who present with certain risk factors.
- Treatment in postmenopausal women and in men age 50 and older with low bone mass at the femoral neck, total hip or spine and 10-year hip fracture probability of 3 percent or more, or, a 10-year major fracture risk of 20 percent or more based on the US-adapted WHO absolute fracture risk model.
- Regular weight-bearing and muscle-strengthening exercise to reduce the risk of falls and fractures.
- Advise on adequate amounts of calcium (at least 1200 mg per day, including supplements (if necessary) and vitamin D (800 to 1000 IU per day of vitamin D for individuals at risk of insufficiency).
"We continue to stress the importance of taking calcium and vitamin D for optimal bone health," says Dawson-Hughes, who has published several papers on the subject. "Previous studies suggest these nutrients help strengthen bones which is beneficial for all adults, even those who show no signs of osteoporosis."
Dawson-Hughes, B, Tosteson, ANA, Melton, LJ III, Baim, S, Favus MJ, Khosla, S, Lindsay RL. Osteoporosis International. 2008 (April); 19: 449-458.
The National Osteoporosis Foundation funded a portion of the study.
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