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New Approach to Prevention of Osteoporotic Fractures

Clinical calculators can help clinicians determine when patients should start receiving osteoporosis therapy.

Decisions to initiate bisphosphonate therapy are uncontroversial for patients who are obviously at high risk (e.g., older women with unequivocal osteoporosis on bone-density testing or people who have already experienced fractures). But for lower-risk patients, such decisions often are made arbitrarily, according to a clinician’s intuition about the relative importance of various risk factors.

To help standardize our approach to prevention and treatment of osteoporosis, a new paradigm called "FRAX" was introduced by the World Health Organization in 2008. The new model was built on results from large observational studies on clinical risk factors for fractures. Clinicians can enter patient-specific information into an online calculator that displays the patient’s 10-year risk for hip fracture; bone-density measurements can also be entered but aren’t required.

Two analyses published in 2008 explain how these 10-year risks can direct treatment in the U.S. One is a cost-effectiveness analysis, in which bisphosphonate therapy becomes cost-effective when the 10-year risk for hip fracture is 3% or greater (Osteoporosis Int 2008; 19:437). In the second analysis, researchers provide tables and figures — generated by the FRAX algorithm — that illustrate fracture risks for various ages, combinations of risk factors, and bone densities (Osteoporosis Int 2008; 19:449). For example, a 65-year-old white woman with a femoral neck T score of –2.0 and no other risk factors would have a 10-year hip-fracture risk of 1.6%, which does not meet the 3% cost-effectiveness threshold. This approach is analogous to that used by the National Cholesterol Education Program for its online calculator, which provides patient-specific 10-year cardiovascular risk information to guide decisions about lipid-lowering drug therapy.

Critics might ask why we should wait until 10-year risk exceeds 3% before initiating bisphosphonate therapy. In my view, at least two responses are appropriate. First, for clinical guidelines not to take cost-effectiveness into consideration is increasingly irresponsible, given the spiraling costs of medical care. And, second, we need more information about the long-term effects of bisphosphonates: Some researchers are concerned that many years of bisphosphonate exposure paradoxically might result in structurally defective bone.

The U.S. National Osteoporosis Foundation (NOF) has embraced this new approach and has incorporated it into a 2008 document, the "Clinician’s Guide to Prevention and Treatment of Osteoporosis." This development is notable, because advocacy organizations such as the NOF often push for aggressive intervention for conditions within their purview, even when supporting evidence is scant and cost-effectiveness is marginal. But, here, the NOF advocates an evidence-based approach, with explicit acknowledgement of the need to consider both individual and societal perspectives.

— Allan S. Brett, MD

Published in Journal Watch General Medicine December 29, 2008

Reader Remarks:

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• NOF guidelines
  Robert Badgett, UTHSCSA, 13 May 2009 2:33 PM EST
  These guidelines seem to ignore all recommendations for the conduct and reporting of clinical practice guidelines.(PMID 13679327; PMID 8460861) At... [more]