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Fracture risk assessment

Fracture risk assessment. Norwich, John A Kanis. SCOOP Launch, November 07. 03ca011. Definition a systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture

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Fracture risk assessment

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  1. Fracture risk assessment Norwich,John A Kanis SCOOP Launch, November 07

  2. 03ca011 Definition a systemic skeletal disease characterised by low bone massand microarchitecturaldeterioration of bone tissue,with a consequent increasein bone fragility andsusceptibility tofracture Consensus Development Conference, 1993 Common sites of fracture Spine 03Osteoporosis Hip Wrist

  3. 99ca160 ex94ca117 from 91ca129 Percent of population 0.6 15 50 85 >99 Osteoporosis Low bone Normal mass Diagnostic thresholds for women -4 -3 -2 -1 0 1 2 3 4 Bone mineral density (SD units or T-score)

  4. - Presence of strong risk factors oestrogen deficiency corticosteroid therapy (>7.5 mg >1 year) maternal history of hip fracture low BMI (<19 kg/m ) - Radiographic osteopenia - Previous fragility fracture - Height loss/ thoracic kyphosis (after radiography) 99ca021 Indications for the diagnostic use of BMD

  5. 04ca226 IOF NOF Case finding strategies

  6. 05ca085 Fractures/1,000 person-years Number of fractures 50 Fracture rate Women with fractures 400 40 300 Osteoporotic fracture and BMD 30 200 20 100 10 0 0 1.0 0.5 0.0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -3.5 Siris. Surgeon General’s Workshop on Osteoporosis and Bone Health, December 2002

  7. Fracture probability (%) Age (years) Women 20 80 70 10 60 50 0 1 -3 -2 -1 0 00ca104 Ten year probability of hip fracture in Sweden T-score (SD)

  8. 04ca148rev Objectives - to optimise sensitivity for fracture risk prediction - case finding or screening strategy - men and women - cost-effective setting - international validity - suitable for primary care Assessment of osteoporosis at primary health care level

  9. 03ca175 Risk factors • Validated in multiple populations • Data for age, sex and type of fracture • Readily assessable by primary care practitioners • Be intuitive rather than counterintuitive to medical care. • Contribute to a risk that is amenable to the therapeutic manipulation intended

  10. 04ca130 Hiroshima CaMoS EVOS / EPOS Rochester Sheffield Rotterdam Gothenburg I Kuopio Gothenberg II Dubbo OFELY EPIDOS Cohorts studied n = 59,232 person-years = 249,898 % female = 74 Any fracture = 5,444 osteoporotic fractures = 3,495 hip fractures = 957

  11. 04ca138 RR/SD 5 Men and women 4 3 Femoral neck BMD and hip fracture prediction 2 1 0 50 55 60 65 70 75 80 85 Age (years)

  12. RR 6 4 2 0 50 55 60 65 70 75 80 85 Age (years) 05ca186 Prior fracture and hip fracture risk

  13. 07ca080 RR (20 v 25 kg/m2) 3.0 Without BMD With BMD 2.0 BMI and fracture risk 1.0 0.0 Osteoporotic fracture Hip fracture

  14. Alcohol >2u FH (hip) Steroids ever Smoking current RA Prior fracture 04ca248 RR 3.0 2.0 Risk factors for hip fracture in men and women 1.0 0.0 Without BMD With BMD

  15. 99ca094 Probability (%) 20 women 15 10-year probability of hip fracture in Malmo 10 5 men 0 50 60 70 80 90 Age (years)

  16. 01ca048 10 year risk (%) 70 60 Ten year probability of hip fracture - Swedish women 50 40 30 6.0 5.0 20 4.0 RR 3.0 10 2.0 0 1.0 50 55 60 65 70 75 80 85 Age (years)

  17. 06ca106 Patient 65 -2.5 FRAX 65 165 24 23.9 8.0

  18. 04ca014 10 year hip fracture probability (%) Mrs X Age = 65 y Height =161cm Weight = 61kg BMI = 23.5 kg/m2 6 4 Clinical risk factors and fracture probability 2 0 FH None Prior Fx Alcohol Steroids Smoking 2o osteoporosis

  19. None Prior fracture +Glucocorticoids +Family history 05ca106 Men Women 10-year probability (%) 70 60 50 Probability of osteoporotic fracture* at age 65 40 30 20 10 0 0 -1 -2 -3 0 -1 -2 -3 T-score US Caucasian, no CRF, BMI=24 *Hip, spine, humerus, forearm

  20. 05ca092 Case finding strategies

  21. 05ca200 Woman aged 65, BMI=24 No Yes Rheumatoid arthritis Stratification of hip fracture risk Yes No No Yes Glucocorticoids No Yes No Yes No No Yes Yes Prior fracture 10-year hip fracture probability (%) 1.5 3.7 3.1 7.5 2.6 6.4 5.4 12.9

  22. 07ca027 RR/SD 6 CRFs BMD CRFs+BMD 5 4 Gradient of risk for hip fracture prediction 3 2 1 50 60 70 80 90 50 60 70 80 90 50 60 70 80 90 Age (years)

  23. Risk ratio (vs. general population) 10 GR=2.6 GR 1.6 2.6 Z-score 2.57 1.63 8 % Population 0.5 5.0 6 GR=1.6 Mean RR 3.5 4.9 4 2 0 -4 -3 -2 -1 0 1 2 3 4 Z-score % 100.0 99.9 97.7 84.1 50.0 15.9 2.3 0.1 0.0 07ca030 Gradient of risk and fracture prediction

  24. 01ca025 Relative probability Very high High Moderate Low risk 1.2 Sweden 1.0 Denmark China (TW) 0.8 Switzerland Australia Netherlands Ten year probability of hip fracture compared with Sweden Finland Greece 0.6 Argentina Hungary Japan France 0.4 China 0.2 Korea 0 Spain Italy Chile USA UK Canada Norway Kuwait Iceland Turkey Germany Portugal Singapore Venezuela China (HK)

  25. 00ca008 End

  26. 04ca191 • Risk amenable to interventionLow BMD Previous fracture Use of glucocorticoids • Presence of risk factor does adversely affect therapeutic responseAge Body mass index Family history of fracture Smoking and alcohol Markers of bone turnover • Uncertain effectsNeuromuscular incompetence Liability to falling Identification of reversible risk

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