Washington, DC— A new guide that incorporates an algorithm assessing 10-year fracture probability may change the way physicians evaluate and treat patients with osteopenia and osteoporosis. The Washington, DC-based National Osteoporosis Foundation (NOF) released on Thursday the Clinician's Guide to Prevention and Treatment of Osteoporosis.¹

The new guide applies the recently released algorithm on absolute fracture risk called FRAXâ„¢ by the World Health Organization (WHO). The algorithm takes bone mineral density (BMD) and 9 specific clinical risk factors into account to estimate a patient's 10-year fracture risk. The algorithm can only be applied to previously untreated patients. To use the new algorithm, doctors can enter a patient's BMD, hip T-score, and other risk factor information in a simple web-based version of the algorithm and obtain absolute fracture risk in seconds.

In the near future, some central DXA (dual X-ray absorptiometry) machines should be able to provide a report that gives information on a person's absolute fracture risk by incorporating the NOF application of the WHO algorithm into the bone density machine's computer.

Risk factors plus T-score equal 10-year fracture risk

"This is a day we have been waiting for a long time," said NOF President Ethel S. Siris, MD, the Madeline C. Stabile professor of clinical medicine and director of the Toni Stabile osteoporosis center at Columbia University Medical Center in New York City. "The new guide allows us to re-introduce the notion that we need to screen appropriate patients with DXA and ask patients older than 50 [several] questions about a variety of risk factors including whether they have ever sustained a fracture," she said. The guide and the algorithm "give us the capacity to look at absolute fracture risk in a much more evidence-based and meaningful way than ever before."

The new algorithm asks questions on age, history of previous fracture, parental fracture history, smoking, alcohol consumption, steroid use, and the presence of certain diseases including rheumatoid arthritis that increase risk of osteoporosis. These are not written in stone, Dr. Siris pointed out. "If you feel you know things about patients that increase their fracture risk [and are not included in the algorithm], use your best judgment."

The absolute fracture risk methodology provides a markedly improved method to assure that people with the highest fracture risk get treated, Dr. Siris said. Those at highest risk include postmenopausal women and older men with a diagnosis of osteoporosis based on a BMD test T-score of <e;-2.5, or those with a clinical diagnosis based on having sustained a hip or spine fracture.

Spotlight on osteopenia

Importantly, the new absolute fracture risk calculations may help to resolve many of the questions about management for people with osteopenia. There are about 30 million individuals with osteopenia who may slip through the cracks if screening is solely based on T-score. The new guide will help physicians to better identify people with osteopenia who are at risk for fracture by also including clinical risk factors in the equation, Dr. Siris explained

The new guide also offers counsel regarding African-American, Asian, Latina, and other postmenopausal women, and for the first time addresses men age >e;50. "A lot of men are not being diagnosed and treated, and hopefully this guide will point us in that direction," said Robert Lindsay, MD, PhD, chief of internal medicine at the Helen Hayes Hospital in West Haverstraw, NY, co-author of the new NOF guide. It also includes updated calcium and vitamin D recommendations: adults age >50 should receive 1200 mg of calcium and 800 IU to1000 IU of vitamin D3 daily.

For more information

To access the WHO algorithm, visit http://www.shef.ac.uk/FRAX/.

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