Osteoporosis

1. Dept. of Internal Medicine I University of Regensburg Dept. of Internal Medicine 2 Klinikum Nürnberg Germany How To Assess The (Fracture) Risk Of Primary Osteoporosis ? 4 th International Seminar on Preventive Geriatrics 1 st International Seminar on Geriatric Rehabilitation Osteoporosis »Prevention and treatment« Athens, 1 st April 2011 Cornelius Bollheimer K LINIKUM N ÜRNBERG

2. Primary – age-related osteoporosis Secondary types of osteoporosis: Primary hyperparathyreodism Hypercortisolism (endogenous / exogenous) Long-standing (male) hypogonadism Renal osteopathy / chronic kidney disease Severe vitamin D deficiency / osteomalacia Multiple myeloma Diagnosis of (i.e. after !) exclusion Filter (lab-values, patient‘s history …) Primary Osteoporosis = Diagnosis Of Exclusion ! !

3. 20 30 40 50 60 70 80 age Individual A Individual B Individual C Severity of osteoporosis Increased fracture Risk Indication for treatment Arbitrary Threshold for osteoporosis Bone mass & quality Assessment Of Osteoporosis  Impeding Fracture Risk

4. Closing In On A Theory Of Everything as assessed by DXA Bone mass + Bone quality as assessed by clinical surrogate parameters + X = Fracture risk of osteoporosis Severity of osteoporosis =

5. Osteoporosis Handling 20 Years Ago Decreased bone mass [ Antiresorptive or bone-forming drugs ] Tertiary prevention Fragility fracture [= 100% fracture risk] 1 2 3

6. Osteoporosis Handling 10 Years Ago Normal distribution of the bone density of 30-year old individuals (gender-specific ) -1 -2,5 Osteoporosis Osteopenia bone mass [T-score] 1 metrological definition Secondary prevention [ Antiresorptive or bone-forming drugs ] 2 Decreased bone mass

7. Surrogate Parameters Of Bone Quality Bone mass + Bone quality influenced by age gender + X = -2,5 -1 0 -2,5 -1 0 10-year hip fracture probability [%] 10-year hip fracture probability [%] Age effect Gender effect [T-score] [T-score] 80yrs Kanis et al [2008] Osteoporos Int Fracture risk of osteoporosis 4 8 12 16 20 4 8 12 16 20 80yrs + 80yrs + 50yrs +

8. DXA Is Not Affordable  2 Step Approach Fracture risk Comparison of the individual results with epidemiological data Bone quality Refined list of clinical surrogate parameters If clinical suspicion is high, then: 3 1 Bone mass 2 Bone density by DXA

9. FRAX = WHO F racture R isk A ssessment Tool http://www.shef.ac.uk/FRAX Clinical parameters associated with bone quality: Low Body mass index Previous low energy fractures Parent hip fracture Current smoking Alcohol consumption Use of glucocorticoids Rheumatoid arthritis Other types of secondary osteoporosis

10. The Lower The BMI, The Higher The Fracture Risk Clinical parameters according FRAX : Kanis et al [2008] Osteoporos Int // http://www.shef.ac.uk/FRAX 0,6 2,3 20 40 10-year hip fracture probability [%] BMI-effect BMI [kg/qm] Low Body mass index Previous low energy fractures Parent hip fracture Current smoking Alcohol consumption Use of glucocorticoids Rheumatoid arthritis Other types of sec. osteoporosis 65yrs + !

11. Conditions Which Roughly Double The Fracture Risk Clinical parameters according FRAX : Kanis et al [2008] Osteoporos Int // http://www.shef.ac.uk/FRAX Low Body mass index Previous low energy fractures Parent hip fracture Current smoking Alcohol consumption Use of glucocorticoids Rheumatoid arthritis Other types of sec. osteoporosis … having occured spontaneously or having arisen from a trauma which in a health individual would not have resulted in a fracture ≥ 3 units per day, i.e. ≥ 750 ml beer ≥ half a bottle of wine ≥ 3 shots of    

12. Oral Glucocorticoids And Rheumatoid Arthritis Clinical parameters according FRAX : http://www.shef.ac.uk/FRAX Low Body mass index Previous low energy fractures Parent hip fracture Current smoking Alcohol consumption Use of glucocorticoids Rheumatoid arthritis Other types of sec. osteoporosis ≥ 5 mg prednisone for ≥ 3 months now or in patient‘s history

13. The Most Labour-Intensive Topic Of FRAX http://www.shef.ac.uk/FRAX Clinical parameters according FRAX : hyperthyroidism type 1 diabetes hypogonadism, premature menopause (< 45 yrs) use of aromatase inhibitors in breast cancer inflammatory bowel disease organ transplantation immobility Low Body mass index Previous low energy fractures Parent hip fracture Current smoking Alcohol consumption Use of glucocorticoids Rheumatoid arthritis Other types of secondary osteoporosis

14. Population-Based Estimate Of The Individual Fracture Risk 10-year fracture probability - for any major osteoporotic fracture - for hip fracture selectively Clinical risk factors +/- DXA [femoral neck] Low Body mass index ___ kg / qm Previous low energy fractures yes ? Parent hip fracture yes ? Current smoking yes ? Alcohol consumption yes ? Use of glucocorticoids yes ? Rheumatoid arthritis yes ? Other secondary osteoporosis yes ? T-score ___ Comparison with epidemiological data

15. 0% 20% 30% 0% 3% 10 year risk of any major osteoporotic fracture [ i.e. spine, hip, shoulder, wrist ] 10 year risk of hip fracture antiresorptive or bone forming agents ? (Consider) 10-Year Fracture Risk - Handling Instructions National Osteoporosis Foundation [2010] Clinician’s Guide to Prevention and Treatment of Osteoporosis // Compston J et al [2009] Maturitas No ! Yes !

17. The Fracture Risk Also Depends On Where You Live Bone mass + Bone quality + X = 3 9 10-year hip fracture probability [%] 6 70yrs Kanis J et al [2002] JBMR 2002 17:1237 // Lippuner et al [2009] Osteoporos Int Fracture risk of osteoporosis 70yrs +

18. European Index Countries very high risk high risk moderate risk Valid epidemiological data according FRAX © EU 1995-2011

20. Conclusions Assessment of primary osteoporosis means assessment of its impeding fracture risk. The DXA-test for bone mineral density is not sufficient and affordable to assess the fracture risk. Clinical risk factors play a growing role in the assessment of osteoporosis. The most important algorithm is the so called FRAX-tool. Based on this clinical information together with an optional DXA a calculation of the individual 10-year fracture risk is possible. Evaluation of osteoporosis has become a computer-based risk assessment by comparison individual information with already existing epidemiological data. 1 2 3 4 5