Awaited Bone Guidelines Target Broader Group for Therapy

Timothy F. Kirn of the Sacramento Bureau contributed to this report.

Updated guidelines slated for release this year should make it easier for physicians and patients to manage osteoporosis and make informed treatment decisions, according to Dr. Bess Dawson-Hughes, director of the bone metabolism laboratory at Tufts University, Boston.

“We are under increasing pressure to develop ways to better identify those patients who will benefit most from treatment,” Dr. Dawson-Hughes said at the annual meeting of the International Society for Clinical Densitometry in Tampa.

The National Osteoporosis Foundation (NOF) is revising its Physician's Guide to Prevention and Treatment of Osteoporosis to incorporate a new World Health Organization (WHO) algorithm that evaluates absolute fracture risk.

Absolute fracture risk is easier for patients to understand than are T scores or z scores, so the phrase “Know your fracture risk” will replace “Know your T score” as the message for patients. The use of absolute fracture risk should allow patients to consider their osteoporosis risk in the context of other chronic disease risks, and to facilitate better decision making concerning osteoporosis treatment, she said.

The need for the updated algorithm is largely to expand treatment to those women who do not clearly have osteoporosis and for whom there has not been a consensus about when to treat—that is, primarily those postmenopausal women whose dual-energy x-ray absorptiometry (DXA) T score is between −1.5 and −2.5, Dr. David L. Kendler, president of the International Society for Clinical Densitometry, explained at the annual meeting of the American Association of Clinical Endocrinologists.

Evidence shows that half or more of low-impact fractures actually occur in this group, he said. In the current NOF guide, treatment is recommended for all postmenopausal women with prior fracture; for postmenopausal women with a T score below −2 and no risk factors; and for postmenopausal women with a T score below −1.5 if they have at least one risk factor.

By comparison, “the [draft] WHO algorithm accounts for the impact of risk factors and for the interactions among risk factors. This is a sophisticated and advanced use of risk factor information,” Dr. Dawson-Hughes said, adding that an advantage of the upcoming NOF guide is that it will better utilize the individual's risk profile to predict fracture.

The new algorithm is based on data from 60,000 subjects. It will enable a physician to estimate a woman's 10-year risk of fracture on the basis of her femoral-neck T score and/or body mass index, together with a number of risk factors. So far, a 12% 10-year risk warrants treatment, although the exact percentage risk that will be used will probably vary by country, Dr. Kendler said.

Corticosteroid use and other secondary causes of osteoporosis are included in the new NOF guide; they are not in the current one, which was issued in 1999. The risk factors are also handled differently, explained Dr. Dawson-Hughes, who is the immediate past president of the NOF.

A case in point: A 60-year-old woman who went through menopause at age 52 and who was not on hormone therapy would have a femoral-neck T score of −1.6.

According to most current osteoporosis guidelines, treatment would not be advised. However, according to the draft WHO algorithm, because she is a smoker and her mother had a hip fracture, her 10-year risk of fracture is actually 15%, and therefore treatment would be warranted, Dr. Kendler said.

The algorithm, which is being developed by Dr. John Kanis of the WHO Collaborating Centre for Metabolic Bone Diseases at the University of Sheffield (England), is expected to be finalized and released this year, Dr. Kendler added.

'We are under increasing pressure to develop' ways to identify patients who will benefit from treatment. DR. DAWSON-HUGHES

Timothy F. Kirn of the Sacramento Bureau contributed to this report.

Updated guidelines slated for release this year should make it easier for physicians and patients to manage osteoporosis and make informed treatment decisions, according to Dr. Bess Dawson-Hughes, director of the bone metabolism laboratory at Tufts University, Boston.

“We are under increasing pressure to develop ways to better identify those patients who will benefit most from treatment,” Dr. Dawson-Hughes said at the annual meeting of the International Society for Clinical Densitometry in Tampa.

The National Osteoporosis Foundation (NOF) is revising its Physician's Guide to Prevention and Treatment of Osteoporosis to incorporate a new World Health Organization (WHO) algorithm that evaluates absolute fracture risk.

Absolute fracture risk is easier for patients to understand than are T scores or z scores, so the phrase “Know your fracture risk” will replace “Know your T score” as the message for patients. The use of absolute fracture risk should allow patients to consider their osteoporosis risk in the context of other chronic disease risks, and to facilitate better decision making concerning osteoporosis treatment, she said.

The need for the updated algorithm is largely to expand treatment to those women who do not clearly have osteoporosis and for whom there has not been a consensus about when to treat—that is, primarily those postmenopausal women whose dual-energy x-ray absorptiometry (DXA) T score is between −1.5 and −2.5, Dr. David L. Kendler, president of the International Society for Clinical Densitometry, explained at the annual meeting of the American Association of Clinical Endocrinologists.

Evidence shows that half or more of low-impact fractures actually occur in this group, he said. In the current NOF guide, treatment is recommended for all postmenopausal women with prior fracture; for postmenopausal women with a T score below −2 and no risk factors; and for postmenopausal women with a T score below −1.5 if they have at least one risk factor.

By comparison, “the [draft] WHO algorithm accounts for the impact of risk factors and for the interactions among risk factors. This is a sophisticated and advanced use of risk factor information,” Dr. Dawson-Hughes said, adding that an advantage of the upcoming NOF guide is that it will better utilize the individual's risk profile to predict fracture.

The new algorithm is based on data from 60,000 subjects. It will enable a physician to estimate a woman's 10-year risk of fracture on the basis of her femoral-neck T score and/or body mass index, together with a number of risk factors. So far, a 12% 10-year risk warrants treatment, although the exact percentage risk that will be used will probably vary by country, Dr. Kendler said.

Corticosteroid use and other secondary causes of osteoporosis are included in the new NOF guide; they are not in the current one, which was issued in 1999. The risk factors are also handled differently, explained Dr. Dawson-Hughes, who is the immediate past president of the NOF.

A case in point: A 60-year-old woman who went through menopause at age 52 and who was not on hormone therapy would have a femoral-neck T score of −1.6.

According to most current osteoporosis guidelines, treatment would not be advised. However, according to the draft WHO algorithm, because she is a smoker and her mother had a hip fracture, her 10-year risk of fracture is actually 15%, and therefore treatment would be warranted, Dr. Kendler said.

The algorithm, which is being developed by Dr. John Kanis of the WHO Collaborating Centre for Metabolic Bone Diseases at the University of Sheffield (England), is expected to be finalized and released this year, Dr. Kendler added.

'We are under increasing pressure to develop' ways to identify patients who will benefit from treatment. DR. DAWSON-HUGHES

Timothy F. Kirn of the Sacramento Bureau contributed to this report.

Updated guidelines slated for release this year should make it easier for physicians and patients to manage osteoporosis and make informed treatment decisions, according to Dr. Bess Dawson-Hughes, director of the bone metabolism laboratory at Tufts University, Boston.

“We are under increasing pressure to develop ways to better identify those patients who will benefit most from treatment,” Dr. Dawson-Hughes said at the annual meeting of the International Society for Clinical Densitometry in Tampa.

The National Osteoporosis Foundation (NOF) is revising its Physician's Guide to Prevention and Treatment of Osteoporosis to incorporate a new World Health Organization (WHO) algorithm that evaluates absolute fracture risk.

Absolute fracture risk is easier for patients to understand than are T scores or z scores, so the phrase “Know your fracture risk” will replace “Know your T score” as the message for patients. The use of absolute fracture risk should allow patients to consider their osteoporosis risk in the context of other chronic disease risks, and to facilitate better decision making concerning osteoporosis treatment, she said.

The need for the updated algorithm is largely to expand treatment to those women who do not clearly have osteoporosis and for whom there has not been a consensus about when to treat—that is, primarily those postmenopausal women whose dual-energy x-ray absorptiometry (DXA) T score is between −1.5 and −2.5, Dr. David L. Kendler, president of the International Society for Clinical Densitometry, explained at the annual meeting of the American Association of Clinical Endocrinologists.

Evidence shows that half or more of low-impact fractures actually occur in this group, he said. In the current NOF guide, treatment is recommended for all postmenopausal women with prior fracture; for postmenopausal women with a T score below −2 and no risk factors; and for postmenopausal women with a T score below −1.5 if they have at least one risk factor.

By comparison, “the [draft] WHO algorithm accounts for the impact of risk factors and for the interactions among risk factors. This is a sophisticated and advanced use of risk factor information,” Dr. Dawson-Hughes said, adding that an advantage of the upcoming NOF guide is that it will better utilize the individual's risk profile to predict fracture.

The new algorithm is based on data from 60,000 subjects. It will enable a physician to estimate a woman's 10-year risk of fracture on the basis of her femoral-neck T score and/or body mass index, together with a number of risk factors. So far, a 12% 10-year risk warrants treatment, although the exact percentage risk that will be used will probably vary by country, Dr. Kendler said.

Corticosteroid use and other secondary causes of osteoporosis are included in the new NOF guide; they are not in the current one, which was issued in 1999. The risk factors are also handled differently, explained Dr. Dawson-Hughes, who is the immediate past president of the NOF.

A case in point: A 60-year-old woman who went through menopause at age 52 and who was not on hormone therapy would have a femoral-neck T score of −1.6.

According to most current osteoporosis guidelines, treatment would not be advised. However, according to the draft WHO algorithm, because she is a smoker and her mother had a hip fracture, her 10-year risk of fracture is actually 15%, and therefore treatment would be warranted, Dr. Kendler said.

The algorithm, which is being developed by Dr. John Kanis of the WHO Collaborating Centre for Metabolic Bone Diseases at the University of Sheffield (England), is expected to be finalized and released this year, Dr. Kendler added.

'We are under increasing pressure to develop' ways to identify patients who will benefit from treatment. DR. DAWSON-HUGHES