Cent Eur J Med.2013 Oct;8(5):571-576.

Fracture risk prediction with FRAX in Slovak postmenopausal women

Eva Némethová, Zdenko Killinger, Juraj Payer

Department of Internal Medicine, Faculty of Medicine Comenius University and University Hospital Ružinov, Bratislava, 82606, Slovakia

 

Abstract

Introduction

Current Slovak treatment thresholds in osteoporosis are based on bone mineral density (BMD) or a previous fracture. Some patients at high risk for fractures may not be identified. FRAX (Fracture Risk Assessment Tool) is based on patient risk profile assessment and calculates 10-year fracture risks. Using FRAX, treatment initiation could be more patient-specific.

Aim of study

To evaluate the risk profile with FRAX in slovak postmenopausal women, to identify those at high risk of fracture according to NOF (National Osteporosis Foundation) intervention thresholds based on FRAX and to compare this approach to current treatment thresholds.

Methods

We measured BMD at lumbar spine, femoral neck, total hip and calculated 10-year absolute fracture risks with the slovak version of FRAX in 365 patients.

Results

Average risk of major osteoporotic fracture was 10,39% and hip fracture 3,00%. 109 patients were eligible for treatment according to actual treatment criteria (88 based on BMD and 21 with previous fracture). In addition, 57 high risk osteopenic patients were identified by NOF thresholds using FRAX, who should be also considered for treatment.

Conclusion

Using FRAX and NOF thresholds it’s possible to identify high risk patients who don’t fulfill current treatment criteria but may profit from treatment.

 

Summary

It is now known that more than half of osteoporotic fractures occur in patients with osteopenia. According to current guidelines these patients are not  indicated for antiresorptive treatment in Slovakia, although it is very likely that they will suffer a fracture in the future. Treatment initiation is currently based on BMD in the osteoporotic range or occurrence of a fracture.  Many factors, which affect the results of DXA testing (f.e.: osteoarthrosis at lumbar spine and proximal femur, inborn vertebral deformities or fractures, severe scoliosis) are often not taken into account in clinical practice and can lead subsequently to falsely high BMD results and no treatment. The assessment of vertebral fractures has also its limitations, which can contribute to no treatment initiation in a high risk patient (up to 2/3 of vertebral fractures are asymptomatic and patients are not sent to X-ray, often mild or moderate vertebral fractures are not described by radiologists and even if they are, they´re evaluated as posttraumatic and not osteoporotic). Morbidity and mortality following a fracture can´t be ignored together with the direct and indirect costs and quality of life. Therefore it is crucial to identify those patients, whose fracture risk is high and in many cases higher than in osteoporotic patients. For this purpose, FRAX – the Fracture risk assessment tool was developed. It consists of 12 independent risk factors of fractures and calculates the absolute 10-year risk of major osteoporotic fractures and hip fractures. With the help of this calculator in deciding whether and who to treat, treatment could be more targeted on high risk patients, who profit from it the most. We were curious how many patients in our population are at high risk of suffering a fracture in the next 10 years. We took a sample of 365 postmenopausal women, measured their BMD and calculated their fracture risks with  FRAX.  Because Slovakia doesn´t have FRAX intervention thresholds set as for example USA does, we used the threshold proposed by NOF (National Osteoporosis Foundation). We compared the number of patients eligible for treatment according to actual treatment criteria with FRAX criteria.

Only approximately half of the osteoporotic patients (who are indicated for treatment according to current guidelines) were also identified by FRAX as being at high risk.  On the other hand, approximately a third of the osteopenic patients (who are not indicated for treatment according to current guidelines) were identified by FRAX as being at high risk.

At this point the question arises whether to treat or not to treat a patient whose BMD is in the osteoporotic range but doesn´t have high fracture risk. Different positions exist, because the most common inclusion criteria in studies proving the efficacy of therapeutic agents on fracture reduction is low BMD. BMD still remains a strong factor in risk prediction. We incline to NOF recommendations, that FRAX should be used when the decision to treat or not to treat is uncertain. We suggest a combined intervention threshold based on BMD and FRAX, which could allow us to target treatment to patients at high fracture risk and would be more sensitive than current thresholds. When considering fracture risks and NOF thresholds in treatment initiation parallel with current criteria in our study, the number of treated patients would rise by 52,3%, which could mean an economic load to our health service. This combined approach will need to be supported by appropriate health economic analyses.

It seems unavoidable to incorporate fracture risk prediction into the treatment decision making process in patients with low BMD in order to treat those patients, who profit from treatment the most. Properly chosen therapeutic thresholds would suppose not only a more targeted but also an economically bearable treatment ( with regards to treatment cost/benefit and local economy).  Therefore, each country besides having an own FRAX model has to review its economic situation and the suitability of NOF intervention thresholds for treatment initiation.

 

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