Review Question - QID 3368

The 2008 National Osteoporosis Foundation Guidelines for Pharmacologic Treatment of Osteoporosis suggests that pharmacologic treatment should be considered for a DEXA T-score between -1.0 and -2.5 at the femoral neck/spine AND 10-year risk of hip fracture ≥ 3%.

Osteoporosis affects more than 12 million Americans per year, with the burden falling heaviest on postmenopausal women. Because of decreased bone strength, patients with osteoporosis are susceptible to fragility fractures. With no additional risk factors, a 65-year-old Caucasian woman has an estimated 10% 10-year risk of a fragility fracture. FRAX (World Health Organization Fracture Risk Assessment Tool) calculates 10-year risk of fracture based on the following variables: age, sex, race, height, weight, BMI, history of fragility fracture, parental history of hip fracture, use of oral glucocorticoids, secondary osteoporosis and alcohol use to calculate 10-year risk of fracture.

Unnanuntana et al. discussed the utility of the FRAX tool as an assessment modality for prediction of fracture risk. The authors advocated for treatment with osteopenia (T-score of -1.0 to -2.5) combined with either a ten-year risk of hip fracture >= 3% or a ten-year risk of major osteoporosis-related fracture of >= 20% as calculated by FRAX. They also discussed biochemical markers of bone formation and resorption, which are useful for monitoring the efficacy of antiresorptive therapy and may help identify patients at high risk for fracture.

Cosman et al. review the 2008 National Osteoporosis Foundation guidelines and support that pharmacologic treatment for osteoporosis should be considered if patients are postmenopausal women or men > 50 years of age AND meet one of the following criteria: have a prior hip or vertebral fracture, a T score -2.5 or less at the femoral neck or spine, OR a T score between -1.0 and -2.5 at the femoral neck or spine AND a 10-year risk of hip fracture greater than 3% or 10-year risk of major osteoporosis-related fracture greater than 20%. They conclude that DEXA scans should be repeated every 1-2 years if patients are undergoing pharmacologic treatment.

Gass et al. review the epidemiology and tiered management strategy for osteoporosis. They discuss the first line prevention, treatment of secondary causes of osteoporosis, and finally pharmacologic interventions, all in an effort to mitigate fracture risk and the burden that osteoporotic fractures on the health care system.

Illustrations:
Illustration A outlines the variables taken into account in the FRAX score calculator.

Incorrect answers:
Answer 1: A DEXA T-score less than -2.5 in isolation is an indication for bisphosphonate therapy. However, in the setting of osteopenia (T-score of -1.0 to -2.5), bisphosphonate therapy is indicated only if the patient ADDITIONALLY has either a ten-year risk of hip fracture >= 3% or a ten-year risk of major osteoporosis-related fracture of >= 20% (or both) as calculated by the FRAX tool.
Answer 2: A 10-year hip fracture risk of >3% as calculated by the FRAX tool in isolation is NOT an indication to begin bisphosphonate therapy. The patient must have documented osteopenia (T-score of -1.0 to -2.5) as well.
Answer 3: A 10-year risk of major osteoporosis-related fracture should be >20% as calculated by the FRAX tool in order to meet the criterion set forth in the 2008 National Osteoporosis Foundation guidelines. Combined with documented osteopenia (T-score of -1.0 to -2.5), bisphosphonate therapy would be indicated.
Answer 5: A 10-year risk of major osteoporosis-related fracture should be >20% as calculated by the FRAX tool in order to meet the criterion set forth in the 2008 National Osteoporosis Foundation guidelines.