FRAX mode d emploi JC RUIZ AFEM 2010 (Fracture Rate Assessment X)
Slide Kit - International Osteoporosis...
Transcript of Slide Kit - International Osteoporosis...
Slide Kit
Title page
Annotations• Osteoporosisshouldberecognisedasimportantpublichealthcon-
cernbecauseofthefracturesthatarise.
• For the year 2000, there were an estimated 9million new oste-oporoticfractures,ofwhich1.6millionwereatthehip,1.7millionwereattheforearmand1.4millionwereclinicalvertebralfractures.EuropeandtheAmericasaccountedfor51%ofallthesefractures,whilemostoftheremainderoccurredintheWesternPacificregionandSoutheastAsia.
• TheWHOfractureriskassessmenttool(FRAX®)identifiesthosepeo-pleathighestriskoffractureanditsapplicationcanbeusedinclini-calsettingsforinformedinterventiondecisions.
Slide1
The aim of the clinician in managing osteoporosis
Annotations• AnIOFsurvey,conductedin11countries,showeddenialofpersonal
riskbypostmenopausalwomen,lackofdialogueaboutosteoporosiswiththeirdoctor,andrestrictedaccesstodiagnosisandtreatmentbeforethefirstfractureresultinunderdiagnosisandundertreatmentofthedisease.
• TheGlobalLongitudinal studyofOsteoporosis inWomen(GLOW)indicated thatover theageof55years,55%ofwomenwithos-teoporosis and 75% ofwomenwith osteopenia perceived them-selvestohavethesameoralowerfractureriskthananage-matchedhealthywoman.
ReferencesJohnellOandKanisJA(2006)Osteoporosis International 17:1726
ReferencesJapaneseOsteoporosisFoundationandtheInternationalOsteoporosisFoundation(2000)Howfragileisherfuture?SurveyReport<http://www.iofbonehealth.org/policy-advocacy/survey-reports.html/>CooperC,SirisE,AdachiJ,etal.(2009)Osteoporosis International20(Suppl.1):S5-S22
Slide2
Predicting fractures with bone mineral density (BMD)
Annotations• BMDisastrongpredictoroffracturerisk.
• Womenwithosteoporosis (BMDT-score≤-2.5) areathigh riskoffracture,buttherearerelativelyfewsuchwomeninthepopulation.
• ThemajorityoffracturesoccurinwomenwithBMDabovetheoste-oporosisthreshold(osteopenia).
• Additionalriskfactorsneedtobetakenintoaccount.
ReferencesSirisE,ChenY-T,AbbottTA,etal.(2004)Archives of Internal Medicine164:1108
Slide4
Fracture probability is age- and BMD-specific
Annotations• The combination of age and BMD improves the estimation of
fractureprobabilities.
• An80yearoldwiththesameT-scoreasa50yearoldhasamuchhigher10-yearprobabilityoffracture.
• Notethata50-yearoldwomanwithosteoporosishasa lower10-yearhipfractureprobabilitycomparedtoa70-yearoldwithosteopenia.
Slide5
Fracture probability is dependent on body mass index (BMI)
Annotations• A lowBMI isa significant risk factor forosteoporotic fractures,
particularlyhipfractures.
• The impactofBMIonosteoporosisfracturerisk is largelymedi-atedthroughitseffectonBMD.
• Forhipfractures,lowBMIremainsasignificantBMD-independentriskfactor.
ReferencesKanisJA,JohnellO,OdenA,etal.(2001)Osteoporosis International12:989
ReferencesDeLaetC,KanisJA,OdenA,etal.(2005)Osteoporosis International 16:1330
Slide3
Fracture probability is age- and gender-specific
Annotations• Ageisanimportantindependentriskfactor.
• Theprobabilityof fracture increases steadilyup to80-85years,andthereafterdecreasessincetheincreaseinmortalityriskwithageexceedstheincreaseinhipfracturerisk.
ReferencesKanisJA,JohnellO,OdenAetal.(2000)Osteoporosis International 11:669
Slide7
Accumulation of risk factors increases fracture probability
Annotations• AstheclinicalriskfactorsusedinFRAX®actindependently,the
accumulationofriskfactorsincreasesfractureprobabilityinbothwomenandmen.
• Fractureprobability isdependentonthenumberofclinicalriskfactors.
• Cumulativeeffectsareseeninbothwomenandmen,withhigh-erfractureprobabilitiesinwomenforthesameBMDT-score.
Slide8
Fracture probability is country-specific
Annotations• Theriskofosteoporoticfracturesdiffersbyupto10-foldfrom
countrytocountry.
• Mortalityratesalsodiffersignificantlybetweencountries.
• Bothratesneedtobeknownforacountry-specificmodeltobeincludedinFRAX®.
• Ethnicity is not taken into account,with the exception of theUnitedStateswherethereissufficientepidemiologicalinforma-tiontomaketheappropriateadjustments.
• FRAX®willexpandtoothercountriesaspopulation-basedepide-miologicdatabecomeavailable
ReferencesKanisJA,JohnellO,OdenA,etal.(2008)Osteoporosis International 19:385
ReferencesKanisJA,JohnellO,OdenA,etal.(2002)JournalofBoneandMineralResearch17(7):1237ElfforsI,AllanderE,KanisJA,etal.(1994)Osteoporosis International 4:253
Slide6
FRAX® makes use of independent risk factors
Annotations• Theriskfactorslistedinthegraph,usedbyFRAX®,aresignificant
contributors toosteoporotic fracture risk, over andabove thatprovidedbyBMDandage.
• Thedifferent contributionof these clinical risk factors is takenintoaccount incalculating the10-year fractureprobabilities inFRAX®.
ReferencesKanisJA,BorgströmF,DeLaetC,etal.(2005)Osteoporosis International16:581
Slide10
Limitations of FRAX®
Annotations• FRAX®iswellvalidated,butnomodelisperfect.
• Furtherriskfactorsmaybeincorporatedinthefuture.
• FRAX®shouldnotbeseenasasubstitutefortheneedtoimproveeducationaboutosteoporosismanagement.
Slide11
Stratification of major osteoporotic fracture risk
Annotations• The stratification of fracture risk helps understand how the
FRAX®toolmayapplyinindividualpatient-basedscenariosandclinicalpractice.
• Thisslideisanexampleofwhatgenerallyhappensinclinicalset-tingstoidentifyapatientatriskofosteoporoticfracture.
• Although the calculationof 10-year fractureprobabilities doesnot replaceclinical judgment, theclinician isprovided throughFRAX®withcomputedprobabilitiesderivedfromevidence-basedepidemiologicaldata.
• InthisspecificUKexample,awomenwithratherthanwithoutrheumatoidarthritis,inthepresenceofapriorfractureandglu-cocorticoiduse,hada33%increaseinfractureprobability(35%insteadof26%).
ReferencesKanisJA,JohnellO,OdenA,etal.(2008)Osteoporosis International 19:385
ReferencesKanisJA,JohnellO,OdenA,etal.(2008)Osteoporosis International19:385
Slide9
WHO fracture risk assessment tool (FRAX®)
Annotations• Reasonsforriskfactorselection:
-Dataavailability
-Internationallyvalidated
-Easilyascertainable
- Evidence that the identified risk ismodifiableby subsequenttreatment
-GoodintuitivevalueReferenceshttp://www.shef.ac.uk/FRAX/index.htm
Slide13
Management of osteoporosis using fracture probabilities
Annotations• ThisUKexampledemonstrateshowfractureprobabilities,com-
putedfromFRAX®,havebeenusedinthedevelopmentonna-tionalguidelinesforthemanagementofosteoporosis.
• Therighthandpanelshowstheinterventionthresholdsetatafractureprobabilityequivalenttoawomanwithapreviousfragil-ityfracture.BMDtestingisrecommendedinindividualsinwhomfractureprobabilities(assessedfromclinicalriskfactorsalone)isclosetotheinterventionthreshold(lefthandpanel).
• Thisminimisestheriskofmisclassifyingahighriskpatientaslowriskandviceversa.
• Thisapproachmaynotbeapplicable toothercountrieswherebonemineraldensitytestingmaybemoreorlessavailable,wherefractureprobabilitiesandthecostoffractureortreatmentdifferfromtheUK.
• AssessmentandinterventionthresholdsshouldbesetnationallytodetermineatwhichlevelthefractureprobabilityisacceptablyhighenoughtorecommendBMDevaluationorpharmaceuticaltreatment.
ReferencesKanisJA,McCloskeyEV,JohanssonH,etal.(2009)Osteoporosis International 20:449;Erratumto(2008)Osteoporo-sis International19:1395
Slide12
WHO Case finding strategies
Annotations• InMemberStateswithnoaccesstoBMDtesting,treatmentcan
be allocatedon thebasis of fractureprobability only, assessedfromapatient’sclinicalriskfactors.
• InMemberStateswhereBMDtesting is recommended in seg-mentsofthepopulation,BMDtestingcanbeperformedalong-sidetheassessmentoffractureprobabilityusingclinicalriskfac-tors.
• MemberStateswithlimitedaccesstoBMDtestingliesomewhereinbetweenandBMDtesting isdependentonclinicalpractice,availability,affordabilityorhealtheconomiccriteria.
ReferencesKanisJAonbehalfoftheWorldHealthOrganizationScientificGroup(2008)Assessmentofosteoporosisattheprimaryhealthcarelevel.TechnicalReport.WHOCollaboratingCentre,UniversityofSheffield,UK.