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NICE-CG 146 Osteoporosis: assessing the risk of fragility fracture Feb 2017 Targeting risk assessment
o In all women aged 65 years and over and all men aged 75 years and over
o in women aged under 65 years and men aged under 75 years in the presence of risk factors, for example:
previous fragility fracture current use or frequent recent use of oral or systemic glucocorticoids history of falls family history of hip fracture other causes of secondary osteoporosis[7]
low body mass index (BMI) (less than 18.5 kg/m2) smoking alcohol intake of more than 14 units per week for women and more than 21 units
per week for men.
FRAX - cautions• Underestimates fracture risk for dose dependant variables e.g.
smoking,
alcohol,
multiple fractures,
glucocorticoids
• Underestimates risk if
previous clinical vertebral fracture
vertebral fracture risk if lumbar BMD low
Very elderly
• Not accurate for patients on treatment
• Does not include falls risk (qfracture.org.uk includes falls)
Relationship Between BMD and Fracture Risk
T–score
–1SD
2 x
SD – Standard deviation1. Watts NB. Oral Presentation at ASBMR 2001.
%
patien
ts with
vertebral
fractures
0
5
10
15
20
25
30
35
-5 -4 -3 -2 -1 0
1. Black DM, et al. J Bone Miner Res 1999; 14(5):821–828. 2. McClung M, et al. JAMA 1999; 282(7):687–689. 3. Ross PD, et al. Osteoporos Int 1993; 3:120–126.
5.4
4.5
7.4
0
1
2
3
4
5
6
7
8
Study of Osteoporotic Fractures1
MORE2 Ross et al, 19933
Rel
ativ
e R
isk
Presence of Previous Vertebral Fracture Increases the Risk of
Future Vertebral Fracture
Case 1
45 year old lady - No risk FactorsRequests a bone density scan
1. Send for DXA2. Fracture risk assessment3. Do Nothing
Case 3
• 54 year old lady
• Fractured wrist
• BMI 21
• Maternal hip fracture
1. DXA2. Fracture Risk3. Do nothing
Treatment Benefit Depends on Absolute Risk
Treatment X is associated with a 50% RRR in event rate
Treat 100 patients at 10 % risk over 10 years
90 don’t have an event
– Of 10 who would have an event
– 5 still do
– 5 events prevented(1 in 20 chance of benefit)
Case 5
•A 78 year old lady
•Fractured distal radius
•PMR on steroids several years now 2.5mg daily
•Wedge fractures noted on thoracic radiographs 2016
•Treatment not previously prescribed
Case 664 year old lady
Fractured wrist
Compression fractures several lumbar and thoracic vertebrae most severe at T10 & T12
Intolerant of bisphosphonates