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.