These risk factors include prior fracture, current age, body mass index (without BMD), femoral neck BMD, parent’s history of hip fracture, use of corticosteroids, consumption of more than two alcoholic drinks per day, smoking status, presence of rheumatoid arthritis, and secondary osteoporosis (without BMD).
Easy to use and accessible online at www.shef.ac.uk/FRAX, the program is based on data from 12 large observational cohorts in Europe, North America, Australia, and Asia that included over 60,000 cases and 250,000 patient-years of observation; 26% were men. The online algorithm computes a patient’s 10-year risk of hip and major osteoporotic (clinical vertebral, forearm, hip, and shoulder) fractures.
According to the National Osteoporosis Foundation’s (NOF) 2008 Guidelines, therapy should be initiated in postmenopausal women and men over age 50 years considering the following criteria:
- If the patient has a hip or spine fracture;
- If the BMD T-score in the spine or proximal femur is –2.5 or lower; or
- If the BMD is between –1 and –2.5, and the patient has one of the following: 20% or higher 10-year risk of major fracture, or 3% or higher 10-year risk of hip fracture, as calculated by FRAX.
“The new [ACR] guidelines [will shift] the emphasis of treatment away from a large group of young, healthy, postmenopausal women with low BMD but no other risk factors toward treating an older population with non-BMD risk factors,” Dr. McClung said.
One related criticism of the NOF guidelines is that they do not incorporate the concept of drug treatment to prevent osteoporosis. “But the idea to prevent osteoporosis is a relic from previous times and is neither cost effective nor clinically effective,” Dr. McClung said.
Treatment for Osteoporosis
In an overview of the several pharmacologic strategies now available or in development for osteoporosis, John P. Bilezikian, MD, professor of medicine and pharmacology at the College of Physicians and Surgeons at Columbia University in New York, said that antiresorptive agents increase bone strength by reducing bone turnover. The antiresorptive bisphosphonates include alendronate, risedronate, zoledronate, and ibandronate. These drugs were originally given as daily medications, but less frequent dosing is as effective as daily doses, he said.
The advent of intravenous quarterly ibandronate and yearly zoledronic acid injections has improved compliance with therapy. The Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly (HORIZON) trial with 8,000 patients found that yearly 5-mg IV zoledronic acid reduced the incidence of vertebral and nonvertebral fractures, and the cumulative risk of hip fractures by 40%.1
