Ukrainian frax: criteria for diagnostics and treatment of osteoporosis
Keywords:FRAX®, osteoporosis, borderline intervention, treatment, diagnosis, risk of osteoporotic fractures
Background. Nowadays, FRAX® algorithm is an informative method for evaluation of the risk of osteoporotic fractures, implemented in European and American guidelines for osteoporosis management. However, there are differences in “intervention thresholds” for antiosteoporotic treatment, which depend on the country, the model of health care system and the reimbursement for treatment. Ukrainian version of FRAX appeared in Ukraine in 2016, but the thresholds for intervention have not yet been developed. The purpose of the study was to determine the “thresholds” for the pharmacological treatment of osteoporosis and for additional diagnostic examination of Ukrainian population using national FRAX model. Materials and methods. 3790 outpatients aged 40–90 years (mean age 61.9 ± 10.0 years) were examined. The development of the “thresholds” for intervention and additional assessment of the bone using dual-energy X-ray densitometry (DXA) based on the methodology adopted by the National Osteoporosis Guideline Group in UK, which is further used in European guidelines. Results. There was an increase of the “threshold” for pharmacological intervention (“upper threshold”) with age from 6.6 % at the age of 40 to 13 % at the age of 75–85 years. The “lower threshold” (threshold for additional examination) increased significantly from 2.4 % at the age of 40 to 6.9 % in women aged 85 years. The evaluation strategy begins with an analysis of the history of low-traumatic fracture. In its presence, a decision to start antiosteoporotic treatment without DXA should be made. In patients without history of fracture, calculation of fracture risk according to FRAX is required. When the risk exceeds the limit of the “upper threshold” antiosteoporotic treatment without DXA is recommended, when its values below the limit of “lower threshold” — additional examination or treatment is not required. In case of intermediate risk of fracture a DXA should be conducted with a reassessment of fracture risk and management tactics. Conclusions. The effectiveness of FRAX principles which uses in European guideline, but with particularities of the epidemiology of osteoporotic fractures in Ukraine, has been proved. Although this approach is cost-effective in other countries, its use in Ukraine may differ and may need to be further explored with an economic assessment of costs and benefits.
Kanis JA. Assessment of osteoporosis at the primary health care level. Technical Report. World Health Organization Col-laborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School. 2007. Available from: https://www.sheffield.ac.uk/FRAX/pdfs/WHO_Technical_Report.pdf.
Povoroznуuk VV, Grуgorieva NV, Orlik O, Nishkumay I, Dzerovich NI, Balatska NI. Osteoporosis in the practice of an internist. Кyiv; 2014. 198 p. (in Ukrainian).
Kanis JA, Johansson H, Harvey NC, McCloskey EV. A brief history of FRAX. Arch Osteoporos. 2018 Oct 31;13(1):118. https://doi.org/10.1007/s11657-018-0510-0.
Povoroznуuk VV, Grуgorieva NV. The role of FRAX in predicting fracture risk. Bol', sustavy, pozvonočnik. 2011;(2):19-28. (in Russian).
Kanis JA, Harvey NC, Cooper C, Johansson H, Odén A, McCloskey EV; Advisory Board of the National Osteoporosis Guideline Group. A systematic review of intervention thresholds based on FRAX : A report prepared for the National Os-teoporosis Guideline Group and the International Osteoporosis Foundation. Arch Osteoporos. 2016 Dec;11(1):25. https://doi.org/10.1007/s11657-016-0278-z.
Kanis JA, Cooper C, Rizzoli R, Reginster JY; Scientific Advisory Board of the European Society for Clinical and Eco-nomic Aspects of Osteoporosis (ESCEO) and the Committees of Scientific Advisors and National Societies of the Inter-national Osteoporosis Foundation (IOF). European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. 2019 Jan;30(1):3-44. https://doi.org/10.1007/s00198-018-4704-5.
Cosman F, de Beur SJ, LeBoff MS, et al. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int. 2014 Oct;25(10):2359-81. https://doi.org/10.1007/s00198-014-2794-2.
Povoroznуuk VV, Grуgorieva NV, Kanis JA, McCloskey EV, Johansson H. Ukrainian Version of FRAX: from Creation to Validation. Bol', sustavy, pozvonočnik. 2016;(3):5-14. https://doi.org/10.22141/2224-1507.3.23.2016.85000. (in Ukrainian).
Povoroznyuk VV, Grigoryeva NV. Information value of different models of FRAX in assessing the risk of osteoporotic fractures in women of Ukraine. Bol', sustavy, pozvonočnik. 2013;(2):32-41. https://doi.org/10.22141/2224-1507.2.10.2013.82080. (in Russian).
Povoroznyuk VV, Grigoryeva NV. Evaluation the Potential of the Austrian FRAX Model Use in Predicting the Risk for Osteoporotic Fractures in Ukrainian Women. Bol', sustavy, pozvonočnik. 2013;(3):13-20. https://doi.org/10.22141/2224-1507.3.11.2013.82322. (in Russian).
Povoroznyuk VV, Grygorieva NV, Kanis JA, et al. Epidemiology of hip fracture and the development of FRAX in Ukraine. Arch Osteoporos. 2017 Dec;12(1):53. https://doi.org/10.1007/s11657-017-0343-2.
Kanis JA, Johnell O, Oden A, Johansson H, McCloskey E. FRAX and the assessment of fracture probability in men and women from the UK. Osteoporos Int. 2008 Apr;19(4):385-97. https://doi.org/10.1007/s00198-007-0543-5.
Compston J, Cooper A, Cooper C, et al; National Osteoporosis Guideline Group (NOGG). UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos. 2017 Dec;12(1):43. https://doi.org/10.1007/s11657-017-0324-5.
National Clinical Guideline Centre (UK). Osteoporosis: Fragility Fracture Risk: Osteoporosis: Assessing the Risk of Fragili-ty Fracture. London: Royal College of Physicians (UK); 2012 Aug.
Johansson H, Oden A, Johnell O, et al. Optimisation of BMD measurements to identify high risk groups for treatment – a test analysis. J Bone Miner Res. 2004 Jun;19(6):906-13. https://doi.org/10.1359/jbmr.2004.19.6.906.
Kanis JA, McCloskey EV, Johansson H, Strom O, Borgstrom F, Oden A; National Osteoporosis Guideline Group. Case finding for the management of osteoporosis with FRAX--assessment and intervention thresholds for the UK. Osteoporos Int. 2008 Oct;19(10):1395-408. https://doi.org/10.1007/s00198-008-0712-1.
Watts NB, Adler RA, Bilezikian JP, et al; Endocrine Society. Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2012 Jun;97(6):1802-22. https://doi.org/10.1210/jc.2011-3045.
Committee on Practice Bulletins-Gynecology, The American College of Obstetricians and Gynecologists. ACOG Practice Bulletin N. 129. Osteoporosis. Obstet Gynecol. 2012 Sep;120(3):718-34. https://doi.org/10.1097/AOG.0b013e31826dc446.
North American Menopause Society (NAMS). Management of osteoporosis in postmenopausal women position state-ment of The North American Menopause Society. Menopause. 2002 Mar-Apr;9(2):84-101.
Sweet MG, Sweet JM, Jeremiah MP, Galazka SS. Diagnosis and treatment of osteoporosis. Am Fam Physician. 2009 Feb 1;79(3):193-200.
Gralow JR, Biermann JS, Farooki A, et al. NCCN Task Force Report: Bone Health in Cancer Care. J Natl Compr Canc Netw. 2013 Aug;11 Suppl 3:S1-50; quiz S51. https://doi.org/10.6004/jnccn.2013.0215.
Florence R, Allen S, Benedict L, et al. Diagnosis and treatment of osteoporosis. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2013.
Papaioannou A, Morin S, Cheung AM, et al. 2010 clinical practice guidelines for the diagnosis and management of oste-oporosis in Canada: summary CMAJ. 2010 Nov 23;182(17):1864-73. https://doi.org/10.1503/cmaj.100771.
British Columbia Medical Association. BCGuidelines: Osteoporosis: Diagnosis, Treatment and Fracture Prevention. Brit-ish Columbia Ministry of health; 2012.
Khan A, Fortier M; MENOPAUSE AND OSTEOPOROSIS WORKING GROUP. Osteoporosis in menopause. J Obstet Gy-naecol Can. 2014 Sep;36(9):839-840. https://doi.org/10.1016/S1701-2163(15)30489-8.
Nelson HD, Haney EM, Chou R, Dana T, Fu R, Bougatsos C. Screening for Osteoporosis: Systematic Review to Update the 2002 U.S. Preventive Services Task Force Recommendation. Rockville (MD): Agency for Healthcare Research and Quality (US); 2010 Jul. Report No.: 10-05145-EF-1.
Michigan Quality Improvement Consortium. Guideline Management and Prevention of Osteoporosis. Michigan Quality Improvement Consortium; 2014.
Jeremiah MP, Unwin BK, Greenawald MH, Casiano VE. Diagnosis and management of osteoporosis. Am Fam Physi-cian. 2015 Aug 15;92(4):261-8.
Institute for Clinical Systems Improvement. Diagnosis and treatment of osteoporosis. 2013.
Siris ES, Adler R, Bilezikian J, et al. The clinical diagnosis of osteoporosis: a position statement from the National Bone Health Alliance Working Group. Osteoporos Int. 2014 May;25(5):1439-43. https://doi.org/10.1007/s00198-014-2655-z.
Niemethova E, Killinger Z, Payer J. Fracture risk prediction with FRAX in Slovak postmenopausal women. Cent Eur J Med. 2013;8(5):571-86. https://doi.org/10.2478/s11536-013-0205-2.
Kocjan T, Prezelj J, Pfeifer M, Sever MJ, Cokolic M, Zavratnik A. Guidelines for the detection and treatment of osteopo-rosis. Zdravniski Vestnik-Slovenian Medical Journal. 2013;82(4):207-17.
Lakatos P, Szekeres L, Takács I, et al. Magyar Reumatológia. Hungarian. 2011.
Gonçalves MJ, Rodrigues AM, Canhão H, Fonseca JE. Osteoporosis: From bone biology to individual treatment deci-sion. Acta Med Port. 2013 Jul-Aug;26(4):445-55.
Pérez Edo L., Alonso Ruiz A., Roig Vilaseca D, et al. 2011 Up-date of the consensus statement of the Spanish Society of Rheumatology on osteoporosis. Reumatol Clin. 2011 Nov-Dec;7(6):357-79. https://doi.org/10.1016/j.reuma.2011.05.013. (in Spanish).
Etxebarria-Foronda I, Caeiro-Rey JR, Larrainzar-Garijo R, et al. SECOT-GEIOS en osteoporosis y fractura por fra-gilidad. Actualización. Rev Esp Cir Ortop Traumatol. 2015 Nov-Dec;59(6):373-93. https://doi.org/10.1016/j.recot.2015.05.007.
Makras P, Vaiopoulos G, Lyritis GP; Greek National Medicine Agency. 2011 Guidelines for the Diagnosis and Treatment of Osteoporosis in Greece. J Musculoskelet Neuronal Interact. 2012 Mar;12(1):38-42.
Arznei, Vernunft. Osteoporose. Knochenbruch- Krankheit. Pharmig, Verband der pharmazeutischen Industrie; Öster-reichs: 2010.
Body J-J. Aromatase inhibitors-induced bone loss in early breast cancer. BoneKEy reports. 2012. 1. 201. DOI: 10.1038/bonekey.2012.201.
Orimo H, Nakamura T, Hosoi T, et al. Japanese 2011 guidelines for prevention and treatment of osteoporosis--executive summary. Arch Osteoporos. 2012;7:3-20. https://doi.org/10.1007/s11657-012-0109-9.
Lippuner K, Johansson H, Borgström F, Kanis JA, Rizzoli R. Cost-effective intervention thresholds against osteoporotic fractures based on FRAX® in Switzerland. Osteoporos Int. 2012 Nov;23(11):2579-89. https://doi.org/10.1007/s00198-011-1869-6.
Koski AM. Glukokortikoidin aiheuttaman osteoporoosin hoitokaavio. 2013.
Kim JW, Jeon YJ, Baek DH, Kim TN, Chang JS. Percentage of the population at high risk of osteoporotic fracture in South Korea: analysis of the 2010 Fifth Korean National Health and Nutrition Examination survey data. Osteoporos Int. 2014 Apr;25(4):1313-9. https://doi.org/10.1007/s00198-013-2595-z.
Grossman JM, Gordon R, Ranganath VK, et al. American College of Rheumatology 2010 recommendations for the pre-vention and treatment of glucocorticoid-induced osteoporosis. Arthritis Care Res (Hoboken). 2010 Nov;62(11):1515-26. https://doi.org/10.1002/acr.20295.
Johansson H, Kanis JA, Oden A, Johnell O, McCloskey E. BMD, clinical risk factors and their combination for hip frac-ture prevention. Osteoporos Int. 2009 Oct;20(10):1675-82. https://doi.org/10.1007/s00198-009-0845-x.
Leslie WD, Majumdar SR, Lix LM, et al; Manitoba Bone Density Program. High fracture probability with FRAX® usual-ly indicates densitometric osteoporosis: implications for clinical practice. Osteoporos Int. 2012 Jan;23(1):391-7. https://doi.org/10.1007/s00198-011-1592-3.
Kanis JA, McCloskey E, Johansson H, Oden A, Leslie WD. FRAX® with and without BMD. Calcif Tissue Int. 2012 Jan;90(1):1-13. https://doi.org/10.1007/s00223-011-9544-7.
Leslie WD, Morin S, Lix LM, et al. Fracture risk assessment without bone density measurement in routine clinical prac-tice. Osteoporos Int. 2012 Jan;23(1):75-85. https://doi.org/10.1007/s00198-011-1747-2.
Cauley JA, Robbins J, Chen Z, et al; Women's Health Initiative Investigators. Effects of estrogen plus progestin on risk of fracture and bone mineral density: the Women’s Health Initiative randomized trial. JAMA. 2003 Oct 1;290(13):1729-38. https://doi.org/10.1001/jama.290.13.1729.
McCloskey EV, Beneton M, Charlesworth D, et al. 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. 2007 Jan;22(1):135-41. https://doi.org/10.1359/jbmr.061008.
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