Underestimated fracture risk in postmenopausal women—application of the hybrid intervention threshold
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This study evaluated the fragility fracture risk of Taiwanese postmenopausal women with osteopenia. With the incorporation of FRAX and hybrid intervention threshold (HIT), 25% of the participants had high fracture risk. We suggest intervention for fragility fracture for postmenopausal women should be guided by FRAX and HIT instead of bone mineral density alone.
To explore the risk of fragility fracture in Taiwanese postmenopausal women with osteopenia using the hybrid intervention threshold (HIT) and Fracture Risk Assessment tool (FRAX).
The Taiwan Osteoporosis Association (TOA) conducted a nationwide bone mineral density (BMD) survey between 2008 and 2011 using a bus equipped with a dual-energy X-ray absorptiometry (DXA) machine. All participants completed a structured questionnaire, which included the elements in the FRAX. Based on the results, the group made up of postmenopausal women with osteopenia was identified. In order to explore the risk of fragility fracture by HIT and FRAX among Taiwan postmenopausal women with osteopenia, the 10-year probability of fracture (FRAX score) and individual intervention threshold (IIT) in this group were calculated. If the FRAX score of a participant was higher than or equal to the IIT or fixed intervention threshold (FIT), the participant was considered as above the HIT (HIT could be reached by being over a threshold at either major osteoporotic fracture or hip fracture) and categorized as having a high FRAX fracture risk.
A total of 13,068 postmenopausal women were enrolled in the program. A total of 5743 (43.9%) participants had osteopenia, of which 1434 (25.0%) had high FRAX fracture risk.
One quarter of Taiwanese postmenopausal women with osteopenia had high fragility fracture risk evaluated by FRAX and HIT. Due to the poor sensitivity of BMD for fragility fracture, we suggest that intervention for fragility fracture for postmenopausal women should also be guided by FRAX and HIT instead of BMD alone.
KeywordsFRAX Intervention threshold Menopause Osteopenia
We are indebted to the TOA for authorizing the use and management of the database. We are also grateful to the Merck Sharp & Dohme pharmaceutical company (Taiwan) for allowing us to use the mobile DXA machine during the recruitment period. We also appreciate the help of Hsu MC in performing the statistical analyses.
Funding for this work was provided through grant CMRPG8D0651 from the Chang Gung Memorial Hospital (https://www.cgmh.org.tw/)
Compliance with ethical standards
This study was approved by the local Institutional Review Board of Chang Gung Memorial Hospital (102-1878B). All participants provided written informed consent prior to participating in this program.
Conflicts of interest
- 8.Drug payment criteria. Chapter 5. Hormones & drugs affecting hormonal mechanism. Section 5.6 Anti-osteoporotic medications. National Health Insurance Administration Ministry of Health and Welfare. https://www.nhi.gov.tw/Content_List.aspx?n=E70D4F1BD029DC37&topn=3FC7D09599D25979. Assessed 17 April 2019
- 9.Kanis JA, Harvey NC, Cooper C, Johansson H, Oden A, McCloskey EV (2016) A systematic review of intervention thresholds based on FRAX: a report prepared for the National Osteoporosis Guideline Group and the International Osteoporosis Foundation. Arch Osteoporos 11:25. https://doi.org/10.1007/s11657-016-0278-z CrossRefPubMedPubMedCentralGoogle Scholar
- 11.WHO scientific group on the assessment of osteoporosis at primary health care level https://www.who.int/chp/topics/Osteoporosis.pdf. Assessed 17 April 2019
- 12.FRAX (Fracture Risk Assessment Tool): Taiwan. https://www.sheffield.ac.uk/FRAX/tool.aspx?country=26. Assessed 17 April 2019
- 17.McCloskey E, Kanis JA, Johansson H, Harvey N, Oden A, Cooper A, Cooper C, Francis RM, Reid DM, Marsh D, Selby P, Thompson F, Hewitt S, Compston J (2015) FRAX-based assessment and intervention thresholds--an exploration of thresholds in women aged 50 years and older in the UK. Osteoporos Int 26:2091–2099. https://doi.org/10.1007/s00198-015-3176-0 CrossRefPubMedGoogle Scholar
- 18.Orimo H, Nakamura T, Hosoi T, Iki M, Uenishi K, Endo N, Ohta H, Shiraki M, Sugimoto T, Suzuki T, Soen S, Nishizawa Y, Hagino H, Fukunaga M, Fujiwara S (2012) Japanese 2011 guidelines for prevention and treatment of osteoporosis--executive summary. Arch Osteoporos 7:3–20. https://doi.org/10.1007/s11657-012-0109-9 CrossRefPubMedPubMedCentralGoogle Scholar
- 22.Lekamwasam S, Adachi JD, Agnusdei D, Bilezikian J, Boonen S, Borgstrom F, Cooper C, Diez Perez A, Eastell R, Hofbauer LC, Kanis JA, Langdahl BL, Lesnyak O, Lorenc R, McCloskey E, Messina OD, Napoli N, Obermayer-Pietsch B, Ralston SH, Sambrook PN, Silverman S, Sosa M, Stepan J, Suppan G, Wahl DA, Compston JE (2012) A framework for the development of guidelines for the management of glucocorticoid-induced osteoporosis. Osteoporos Int 23:2257–2276. https://doi.org/10.1007/s00198-012-1958-1 CrossRefPubMedGoogle Scholar
- 23.Black DM, Delmas PD, Eastell R, Reid IR, Boonen S, Cauley JA, Cosman F, Lakatos P, Leung PC, Man Z, Mautalen C, Mesenbrink P, Hu H, Caminis J, Tong K, Rosario-Jansen T, Krasnow J, Hue TF, Sellmeyer D, Eriksen EF, Cummings SR (2007) Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. N Engl J Med 356:1809–1822. https://doi.org/10.1056/NEJMoa067312 CrossRefGoogle Scholar
- 24.Cummings SR, San Martin J, McClung MR, Siris ES, Eastell R, Reid IR, Delmas P, Zoog HB, Austin M, Wang A, Kutilek S, Adami S, Zanchetta J, Libanati C, Siddhanti S, Christiansen C (2009) Denosumab for prevention of fractures in postmenopausal women with osteoporosis. N Engl J Med 361:756–765. https://doi.org/10.1056/NEJMoa0809493 CrossRefPubMedGoogle Scholar
- 25.Liberman UA, Weiss SR, Broll J, Minne HW, Quan H, Bell NH, Rodriguez-Portales J, Downs RW Jr, Dequeker J, Favus M (1995) Effect of oral alendronate on bone mineral density and the incidence of fractures in postmenopausal osteoporosis. The Alendronate Phase III Osteoporosis Treatment Study Group. N Engl J Med 333:1437–1443. https://doi.org/10.1056/nejm199511303332201 CrossRefPubMedGoogle Scholar
- 26.Neer RM, Arnaud CD, Zanchetta JR, Prince R, Gaich GA, Reginster JY, Hodsman AB, Eriksen EF, Ish-Shalom S, Genant HK, Wang O, Mitlak BH (2001) Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med 344:1434–1441. https://doi.org/10.1056/nejm200105103441904 CrossRefPubMedGoogle Scholar
- 28.McCloskey EV, Johansson H, Oden A, Austin M, Siris E, Wang A, Lewiecki EM, Lorenc R, Libanati C, Kanis JA (2012) Denosumab reduces the risk of osteoporotic fractures in postmenopausal women, particularly in those with moderate to high fracture risk as assessed with FRAX. J Bone Miner Res 27:1480–1486. https://doi.org/10.1002/jbmr.1606 CrossRefPubMedGoogle Scholar
- 29.McCloskey EV, Johansson H, Oden A, Vasireddy S, Kayan K, Pande K, Jalava T, Kanis JA (2009) Ten-year fracture probability identifies women who will benefit from clodronate therapy--additional results from a double-blind, placebo-controlled randomised study. Osteoporos Int 20:811–817. https://doi.org/10.1007/s00198-008-0786-9 CrossRefPubMedGoogle Scholar
- 30.McCloskey EV, Beneton M, Charlesworth D, Kayan K, deTakats D, Dey A, Orgee J, Ashford R, Forster M, Cliffe J, Kersh L, Brazier J, Nichol J, Aropuu S, Jalava T, Kanis JA (2007) Clodronate reduces the incidence of fractures in community-dwelling elderly women unselected for osteoporosis: results of a double-blind, placebo-controlled randomized study. J Bone Miner Res 22:135–141. https://doi.org/10.1359/jbmr.061008 CrossRefPubMedGoogle Scholar
- 32.Shepstone L, Lenaghan E, Cooper C, Clarke S, Fong-Soe-Khioe R, Fordham R, Gittoes N, Harvey I, Harvey N, Heawood A, Holland R, Howe A, Kanis J, Marshall T, O'Neill T, Peters T, Redmond N, Torgerson D, Turner D, McCloskey E (2018) Screening in the community to reduce fractures in older women (SCOOP): a randomised controlled trial. Lancet 391:741–747. https://doi.org/10.1016/s0140-6736(17)32640-5 CrossRefPubMedGoogle Scholar
- 34.Hernlund E, Svedbom A, Ivergard M, Compston J, Cooper C, Stenmark J, McCloskey EV, Jonsson B, Kanis JA (2013) Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos 8:136. https://doi.org/10.1007/s11657-013-0136-1 CrossRefPubMedPubMedCentralGoogle Scholar
- 35.Lee J, Lee S, Jang S, Ryu OH (2013) Age-related changes in the prevalence of osteoporosis according to gender and skeletal site: the Korea National Health and Nutrition Examination Survey 2008-2010. Endocrinol Metab (Seoul) 28:180–191. https://doi.org/10.3803/EnM.2013.28.3.180 CrossRefGoogle Scholar
- 37.Wright NC, Looker AC, Saag KG, Curtis JR, Delzell ES, Randall S, Dawson-Hughes B (2014) The recent prevalence of osteoporosis and low bone mass in the United States based on bone mineral density at the femoral neck or lumbar spine. J Bone Miner Res 29:2520–2526. https://doi.org/10.1002/jbmr.2269 CrossRefPubMedPubMedCentralGoogle Scholar