Fracture risk assessment: From Basics to Baffling
Transcript of Fracture risk assessment: From Basics to Baffling
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Fracture risk assessment:
From Basics to Baffling
William D Leslie MD FRCPC MSc CCD
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By the end of this session
attendees shall be able to:
• Understand how and why fracture risk
assessment has changed over the past decade
• Understand how recent advances in fracture risk
assessment enhance the quality of patient care
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1. Leslie WD, et al. Osteoporos Int 2010; 21:1317‐1322.
2. Burge J, et al. J Bone Miner Res 2007; 22:465-475.
3. Public Health Agency of Canada. 2009.
4. Canadian Cancer Society/National Cancer Institute of Canada. 2007.
22,30019,50022,200
21,200
Hip
31,100
Wrist
9,800
Pelvic
39,500
Other
37,000
Vertebral
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
Osteoporotic
Fractures
Heart
Attack
Stroke Breast
Cancer
Ann
ual I
ncid
ence
of C
omm
on D
isea
ses
138,600
Incidence of Osteoporotic Fracture, Heart Attack,
Stroke and Breast Cancer in Canadian Women
3 41,2
3
*
* Canadian hip fractures from (1). Non-hip fractures extrapolated from (2).
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Fragility Fracture: Definition
• A fracture occurring
spontaneously or
following minor
trauma such as a fall
from standing height
or less1,2
– Excluding face/head,
hand, ankle, and foot
fractures
1. Kanis JA, et al. Osteoporos Int 2001; 12(5):417-427.
2. Bessette L, et al. Osteoporos Int 2008; 19:79-86.
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Consequences of Fracture
• Increased risk of
– Hospitalization1
– Institutionalization2
– Death3-5
– Subsequent fracture6-8
– Decreased quality of life9-12
– Economic burden on
healthcare system2
1. Papaioannou A, et al. Osteoporos Int 2001; 12(10):870-874.2. Wiktorowicz ME, et al. Osteoporos Int 2001; 12(4):271-278.3. Ioannidis G, et al. CMAJ 2009; 181(5):265-271.4. Papaioannou A, et al. J SOGC 2000; 22(8):591-597.5. Tosteson AN, et al. Osteoporos Int 2007; 18(11):1463-1472.6. Papaioannou A, et al. J SOGC 2000; 22(8):591-597.
7. Colon-Emeric C, et al. Osteoporos Int 2003; 14:879-893.8. Lindsay R, et al. JAMA 2001; 285:320-323.9. Sawka AM, et al. Osteoporos Int 2005; 16:1836-1840.10. Cranney A, et al. J Rheumatol 2005; 32(12):2393-2399.11. Pasco JA, et al. Osteoporos Int 2005; 16(12):2046-2052.12. Papaioannou A, et al. Osteoporos Int 2009; 20(5):703-715.
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Death 1st Year Post Fractureadjusted for age, comorbidity, home care/PCH status
0
0.5
1
1.5
2
2.5
3
3.5
Women Men
RR
fo
r D
ea
th
Hip Spine Humerus Wrist Other
Morin S. Osteoporo Int. 2010.
N=49,197
Incident fractures
N=21,067
Incident fractures
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Post-fracture Care Gap:
Comparison with Heart Attack
~15%
~80%
0
20
40
60
80
100
Anti-osteoporosis medication post fracture
Beta-blockers post heart attack
% o
f p
ati
en
ts b
ein
g t
rea
ted
1. Bessette L, et al. Osteoporos Int 2008; 19:79-86.
2. Austin PC, et al. CMAJ 2008; 179(9):901-908.
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Percentage of individuals who received OP medication 1 year following
major fracture in Canada, 2000–2001 to 2014–2015
0.0
5.0
10.0
15.0
20.0
25.0
30.0P
erc
en
tage
(%)
Fiscal Year
Females - new OP medication prescription Males - new OP medication prescription
Results for Canada
“Up to” 26.1% in Women and 16.9% in Men
Increase up to 2008–2009 (p for trend <0.0001)
Followed by a Decline to 2014–2015 (p for trend <0.0001)
Morin SN et al. ASBMR 2018.
Women Men
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Results for Canada
Brown JP. Can Family Physician 2014.
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• “…all Canadians,
wherever they live,
have the right to
effective bone care
and fracture
prevention programs”
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Key Changes from 20021 to 20102
• Increased focus on the importance of
fragility fractures
• Increased focus on the care gap that
exists in the identification and
treatment of high-risk individuals
1. Brown JP, Josse RG. CMAJ 2002; 167(10 Suppl):S1-34.
2. Papaioannou A, et al. CMAJ 2010.
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No. of fractures
No
. of
frac
ture
s
0
100
200
300
400
500
Most Fragility Fractures in Older Women Occur
with Low Bone Mass ("Osteopenia")
> 0.0 0.0to -0.5
-0.5to -1.0
-1.0to -1.5
-1.5to -2.0
-2.0to -2.5
-2.5to -3.0
-3.0to -3.5
≤ -3.5 Normal Osteo-penia
Osteo-porosis
WHO categoryHip T-score
60
50
40
30
20
10
0
Fracture rate
Frac
ture
rat
e, p
er
10
00
pe
rso
n-y
ear
s
Cranney A, et al. CMAJ 2007; 177(6):575-580.
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Treatment initiation:High risk fracture = vertebral, hip, multiple
Leslie WD et al. Bone 2018.
5%
71%
23%
5%
71%
19%
0%
25%
50%
75%
100%
Normal Osteopenia Osteoporosis
Ost
eo
po
rosi
s tr
ea
tme
nt
No fracture High-risk Fracture
95% CI bars
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2010 Guidelines
Assessment of fracture risk
Moderate riskLow risk High risk10 year fracture risk > 20% or
prior fragility fracture of hip or spine or > 1 fragility fracture)
Good evidence of benefit from
pharmacotherapy
Initial BMD Testing
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10-year MOF Risk Assessment
CAROC 2010FRAX Canada
2010 Guidelines
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10-year Risk Assessment: CAROC
• Semiquantitative method for estimating 10-year
absolute risk of a major osteoporotic fracture* in
postmenopausal women and men over age 50
– Three zones (low: < 10%, moderate, high: > 20%)
• Considers two additional risk factors
– Fragility fracture after age 40
– Recent prolonged systemic glucocorticoid use (at
least 3 m last year prednisone > 7.5 mg daily)
Siminoski K, et al. Can Assoc Radiol J 2005; 56(3):178-188.
* Fractures of the thigh bone, vertebra, forearm, and shoulder
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Example: 65 year old woman
• Femoral neck
T-score = -2.8
• Based on age and
T-score alone =
moderate risk
Adapted from Siminoski K, et al. Can Assoc Radiol J 2005; 56(3):178-188.
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Example: 65 year old woman
• Femoral neck
T-score = -2.8
• Based on age and
T-score alone =
moderate risk
• History of fragility
fracture or prolonged
systemic glucocorticoid
use would shift her
to high risk
Adapted from Siminoski K, et al. Can Assoc Radiol J 2005; 56(3):178-188.
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CAROC: Women ≠ Men
A. Papaioannou et al. CMAJ 2010;182:1864-73B. Lentle et al. CARJ 62:243-250, 2011
MenWomen
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Canadian FRAX Went Live July 2010
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10-year Risk Assessment: FRAX
Leslie WD, et al. J Bone Miner Res 2010.Leslie WD, et al. Osteoporos Int 2010.Fraser L. Osteoporos Int 2010.
10-Year Major Fracture Probability
0
5
10
15
20
25
30
Sw
ed
en
Sw
itze
rla
nd
US
Ca
uca
sia
n
Au
str
ia
Un
ite
d K
ing
do
m
CA
NA
DA
Be
lgiu
m
Ja
pa
n
Ita
ly
Arg
en
tin
a
Ho
ng
Ko
ng
Fin
lan
d
Ge
rma
ny
US
His
pa
nic
US
Asia
n
Fra
nce
Ne
w Z
ea
lan
d
US
Bla
ck
Sp
ain
Le
ba
no
n
Ch
ina
Tu
rke
y
Pe
rce
nt fr
actu
re
Female Male
Age 65 years, prior fracture with femoral neck T-score -2.5
10-Year Hip Fracture Probability
0
2
4
6
8
10
12
Sw
ed
en
Au
str
ia
Be
lgiu
m
Sw
itze
rla
nd
Ita
ly
Un
ite
d K
ing
do
m
Arg
en
tin
a
US
Ca
uca
sia
n
Ho
ng
Ko
ng
Ge
rma
ny
Fin
lan
d
CA
NA
DA
Fra
nce
Ne
w Z
ea
lan
d
Ja
pa
n
Sp
ain
US
His
pa
nic
US
Asia
n
Le
ba
no
n
Ch
ina
US
Bla
ck
Tu
rke
y
Pe
rce
nt fr
actu
re
Female Male
Age 65 years, prior fracture with femoral neck T-score -2.5
Canadian FRAX uses:
• 2005 national hip fracture data
• 2004 national mortality data
• Estimates non-hip fractures from hip fractures
• Predictions validated in >45,000 Canadians
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The site and reference technology is DXA
at the femoral neck. T-scores are based
on the NHANES reference values for
women aged 20-29 years. The same
absolute values are used in men.
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• Without CAROC risk factors: 13% - moderate risk
• History of fragility fracture: 21% - high risk
• Systemic glucocorticoids: 21% - high risk
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FRAX vs Updated 2010 CAROC
CaMos
0%
10%
20%
30%
Full FRAX CanFRAX
10-y
ear
Fra
ctu
res
Low (0-9) Moderate (10-19) High (20+)
2010 CAROC
Same risk category 90% of cases
Leslie WD and the FRAX Working Group. Osteoporos Int 2010.
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Canadian
FRAX
FRAX
Lite
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First Line Therapies with Grade A
Evidence for Fracture Prevention
Type of
Fracture
Antiresorptive therapy
Bone
formation
therapy
Bisphosphonates
Denosumab Raloxifene
Hormone
therapy
(Estrogen)
TeriparatideAlendronate Risedronate
Zoledronic
acid
Vertebral
Hip - -
Non-
vertebral+ -
Papaioannou A, et al. CMAJ 2010 Oct 12.
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Importance of Prior Major Fracture:Re-fracture in 40,062 women and 17,721 men
Morin SN et al. ASBMR 2018.
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Fracture Risk Assessment
Other Factors that Warrant Consideration for Pharmacological Therapy?E.G. LATERAL THORACOLUMBAR IMAGING TO IDENTIFY VERTEBRAL FRACTURES
High Risk10-year fracture risk > 20%
orPrior fragility fracture of hip or SPINE
orMore than one fragility fracture
Good evidence of benefit from pharmacotherapy
Importance of Vertebral Fractures
2010 Guidelines
Papaioannou A, et al. CMAJ 2010.
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Case Finding with VFA
VFA VFA
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Proportions Dispensed Medication
By VFA Results & Risk Category
Diff 25.9%
Diff 25.2%
Diff 9.1%
Schousboe JT et al. ASBMR 2018.
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To Treat or Not to Treat?
• 70 year old woman:
• Breast cancer starting AI therapy
• Low Bone Mass / Osteopenic
• FRAX MOF 31%
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Follow Up
• 72 year old woman:
• Breast cancer on AI therapy for 2 years
• No anti-osteoporosis tx
• Low Bone Mass / Osteopenic
• FRAX MOF 7.3%
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Prior fracture: fell on the ice, injured wrists, x-ray no fracture
Parental hip fracture: adopted
Glucocorticoids: in conjunction with adjuvant breast chemotx
Rheumatoid arthritis: now indicates fibromyalgia
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79 year old woman• Left “wrist” fracture age 55
• fell while curling
• Right radius/ulna fracture age
• stepped off curb
• Type 2 diabetes
• since age 50
• Father hip fracture
• age 102
FRAX Canada without BMD:
• no risk factors: 17%
+ prior fracture: 28%
+ prior fracture + parent hip fracture: 44%
+ prior fracture + RA (diabetes proxy): 38%
X
X
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79 year old woman• Left “wrist” fracture age 55
• fell while curling
• Right radius/ulna fracture age
• stepped off curb
• Type 2 diabetes
• since age 50
• Father hip fracture
• age 102
FRAX Canada with BMD (femur neck T-score -2.2):
• no risk factors: 16%
+ prior fracture: 23%
+ prior fracture + parent hip fracture: 39%
+ prior fracture + RA (diabetes proxy): 29%
X
X
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79 year old woman• Left “wrist” fracture age 55
• fell while curling
• Right radius/ulna fracture age
• stepped off curb
• Type 2 diabetes
• since age 50
• Father hip fracture
• age 102
CAROC with BMD (femur neck T-score -2.2):
• no risk factors: moderate risk
+ prior fracture: high risk
X
XX
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VFA CT
Chest
x-ray
When in doubt….
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FRAX vs CAROC: Summary
FRAX:
• Quantitative
• More risk factors
• Computer based
• Widely used in 2018
• Does not include falls and other risk factors
• Requires clinical judgment
CAROC:
• Semi-quantitative
• Simpler
• Table / graphic based
• Widely used in 2010
• Does not include falls and other risk factors
• Requires clinical judgment
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Concluding Thoughts
• Osteoporosis is much more than DXA
• We have good tools to improve post fracture care