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Osteoporosis
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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
MEDIZIN I UNIVERSITÄT REGENSBURG
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 !
!
MEDIZIN I UNIVERSITÄT REGENSBURG
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
MEDIZIN I UNIVERSITÄT REGENSBURG
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=
MEDIZIN I UNIVERSITÄT REGENSBURG
Osteoporosis Handling 20 Years Ago
Fragilityfracture
[= 100% fracture risk]
1
Decreased bone mass
2
[ Antiresorptive or bone-forming drugs ]
Tertiaryprevention
3
MEDIZIN I UNIVERSITÄT REGENSBURG
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
MEDIZIN I UNIVERSITÄT REGENSBURG
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
MEDIZIN I UNIVERSITÄT REGENSBURG
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:
MEDIZIN I UNIVERSITÄT REGENSBURG
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
MEDIZIN I UNIVERSITÄT REGENSBURG
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
Previous low energy fractures
Parent hip fracture
Current smoking
Alcohol consumption
Use of glucocorticoids
Rheumatoid arthritis
Other types of sec. osteoporosis
!
MEDIZIN I UNIVERSITÄT REGENSBURG
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
Previous low energy fractures
Parent hip fracture
Current smoking
Alcohol consumption
Use of glucocorticoids
Rheumatoid arthritis
Other types of sec. osteoporosis
… 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
MEDIZIN I UNIVERSITÄT REGENSBURG
Oral Glucocorticoids And Rheumatoid Arthritis
Clinical parameters according FRAX:
http://www.shef.ac.uk/FRAX
Low Body mass index
Previous low energy fractures
Parent hip fracture
Current smoking
Alcohol consumption
Use of glucocorticoids
Rheumatoid arthritis
Other types of sec. osteoporosis
≥ 5 mg prednisone for ≥ 3 months
now or in patient‘s history
MEDIZIN I UNIVERSITÄT REGENSBURG
The Most Labour-Intensive Topic Of FRAX
http://www.shef.ac.uk/FRAX
Clinical parameters according 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
Previous low energy fractures
Parent hip fracture
Current smoking
Alcohol consumption
Use of glucocorticoids
Rheumatoid arthritis
Other types of secondary osteoporosis
MEDIZIN I UNIVERSITÄT REGENSBURG
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
MEDIZIN I UNIVERSITÄT REGENSBURG
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
MEDIZIN I UNIVERSITÄT REGENSBURG
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
MEDIZIN I UNIVERSITÄT REGENSBURG
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
MEDIZIN I UNIVERSITÄT REGENSBURG
European Index Countries
very high risk
high risk
moderate risk
Valid epidemiological dataaccording FRAX
© EU 1995-2011
MEDIZIN I UNIVERSITÄT REGENSBURG
MEDIZIN I UNIVERSITÄT REGENSBURG
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.
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