Guidelines to Take Broader View of Fracture Risk

LA JOLLA, CALIF. — Management of osteoporosis is about to undergo some radical changes, including a new international focus on assessing fracture risk in clinical practice and an emphasis on higher doses of vitamin D, said Dr. Stuart L. Silverman at Perspectives in Women's Health sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

“We're changing the whole way in which we approach osteoporosis in 2008,” said Dr. Silverman, who serves with the International Working Group on Fracture Risk Assessment for the World Health Organization.

New guidelines are imminent that will encourage calculation of each patient's fracture risk based not only on bone mineral density and T score, but also on age, body mass index, family history, and other factors, he explained.

This composite fracture score, expected to be incorporated into software linked with dual-energy x-ray absorptiometry (DXA) equipment by late 2008, will provide a much more comprehensive and easy-to-understand risk profile for physicians and their patients, he said.

“Bone density technicians worldwide are going to start asking questions,” said Dr. Silverman, an attending physician in the division of rheumatology at Cedars-Sinai Medical Center in Los Angeles.

“You will get a printout that says your patient has, [for example], a 10-year risk of hip fracture of 3%,” he said.

The calculated 10-year risk for clinical fracture of the shoulder, forearm, or vertebra will also be included in a separate score.

Factors in the 10-year predictions of fracture risk include:

▸ Age, which can change the 10-year risk for a woman with a T score of −2.5 at the femoral neck from 2% at age 50 to 12.5% at age 80.

▸ History of prior fragility fracture, which increases fracture risk fivefold.

▸ Low body weight/BMI.

▸ History of a hip fracture in the patient's mother or father.

▸ Lifetime history of ever using corticosteroids at a dose of 5 mg/day or greater for 3 months or longer.

▸ Current smoking.

▸ Consumption of more than two alcoholic drinks per day.

▸ Secondary osteoporosis caused by a disease process or a drug such as an aromatase inhibitor.

In part, the new international guidelines were driven by pragmatism, because not every country has wide availability of DXA machines, and even when they are accessible, “bone mass is only a snapshot in time,” said Dr. Silverman, who is also from the University of California, Los Angeles.

Factoring in other criteria that are found to influence fracture rates may prove to be more accurate and clinically useful to all physicians, not just those in China, where there are 300 DXA machines and more than 1 billion people. By comparison, there are 20,000 DXA machines and 300 million people in the United States.

“For a long time, the message you've been getting … is that your responsibility as a physician is reducing the risk of osteoporosis. We're not in that mode any more,” he said.

“Your goal is not to reduce risk of osteoporosis, but to reduce the risk of fracture,” he emphasized.

In the general population, only half of the people who fracture also have osteoporosis.

Strategies should focus not only on that 50%, but also on the other 50% of people who have only osteopenia or low bone mass and may be unaware of their risk.

One way in which risk can be reduced is through vitamin D supplementation recommendations, which are also likely to change soon, according to Dr. Silverman.

“Recently, we have all come to appreciate that we really need much more vitamin D,” he said.

“We're pushing for 800 to 1,000 IU day, and I will tell you that a lot of us in the field … are actually taking more than that.”

Findings from new studies show that vitamin D is useful not only for bones, but also for balance and possibly for reducing overall cancer risk, he noted.

FAMILY PRACTICE NEWS is published by the International Medical News Group, a division of Elsevier.

LA JOLLA, CALIF. — Management of osteoporosis is about to undergo some radical changes, including a new international focus on assessing fracture risk in clinical practice and an emphasis on higher doses of vitamin D, said Dr. Stuart L. Silverman at Perspectives in Women's Health sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

“We're changing the whole way in which we approach osteoporosis in 2008,” said Dr. Silverman, who serves with the International Working Group on Fracture Risk Assessment for the World Health Organization.

New guidelines are imminent that will encourage calculation of each patient's fracture risk based not only on bone mineral density and T score, but also on age, body mass index, family history, and other factors, he explained.

This composite fracture score, expected to be incorporated into software linked with dual-energy x-ray absorptiometry (DXA) equipment by late 2008, will provide a much more comprehensive and easy-to-understand risk profile for physicians and their patients, he said.

“Bone density technicians worldwide are going to start asking questions,” said Dr. Silverman, an attending physician in the division of rheumatology at Cedars-Sinai Medical Center in Los Angeles.

“You will get a printout that says your patient has, [for example], a 10-year risk of hip fracture of 3%,” he said.

The calculated 10-year risk for clinical fracture of the shoulder, forearm, or vertebra will also be included in a separate score.

Factors in the 10-year predictions of fracture risk include:

▸ Age, which can change the 10-year risk for a woman with a T score of −2.5 at the femoral neck from 2% at age 50 to 12.5% at age 80.

▸ History of prior fragility fracture, which increases fracture risk fivefold.

▸ Low body weight/BMI.

▸ History of a hip fracture in the patient's mother or father.

▸ Lifetime history of ever using corticosteroids at a dose of 5 mg/day or greater for 3 months or longer.

▸ Current smoking.

▸ Consumption of more than two alcoholic drinks per day.

▸ Secondary osteoporosis caused by a disease process or a drug such as an aromatase inhibitor.

In part, the new international guidelines were driven by pragmatism, because not every country has wide availability of DXA machines, and even when they are accessible, “bone mass is only a snapshot in time,” said Dr. Silverman, who is also from the University of California, Los Angeles.

Factoring in other criteria that are found to influence fracture rates may prove to be more accurate and clinically useful to all physicians, not just those in China, where there are 300 DXA machines and more than 1 billion people. By comparison, there are 20,000 DXA machines and 300 million people in the United States.

“For a long time, the message you've been getting … is that your responsibility as a physician is reducing the risk of osteoporosis. We're not in that mode any more,” he said.

“Your goal is not to reduce risk of osteoporosis, but to reduce the risk of fracture,” he emphasized.

In the general population, only half of the people who fracture also have osteoporosis.

Strategies should focus not only on that 50%, but also on the other 50% of people who have only osteopenia or low bone mass and may be unaware of their risk.

One way in which risk can be reduced is through vitamin D supplementation recommendations, which are also likely to change soon, according to Dr. Silverman.

“Recently, we have all come to appreciate that we really need much more vitamin D,” he said.

“We're pushing for 800 to 1,000 IU day, and I will tell you that a lot of us in the field … are actually taking more than that.”

Findings from new studies show that vitamin D is useful not only for bones, but also for balance and possibly for reducing overall cancer risk, he noted.

FAMILY PRACTICE NEWS is published by the International Medical News Group, a division of Elsevier.

LA JOLLA, CALIF. — Management of osteoporosis is about to undergo some radical changes, including a new international focus on assessing fracture risk in clinical practice and an emphasis on higher doses of vitamin D, said Dr. Stuart L. Silverman at Perspectives in Women's Health sponsored by FAMILY PRACTICE NEWS, OB.GYN. NEWS, and INTERNAL MEDICINE NEWS.

“We're changing the whole way in which we approach osteoporosis in 2008,” said Dr. Silverman, who serves with the International Working Group on Fracture Risk Assessment for the World Health Organization.

New guidelines are imminent that will encourage calculation of each patient's fracture risk based not only on bone mineral density and T score, but also on age, body mass index, family history, and other factors, he explained.

This composite fracture score, expected to be incorporated into software linked with dual-energy x-ray absorptiometry (DXA) equipment by late 2008, will provide a much more comprehensive and easy-to-understand risk profile for physicians and their patients, he said.

“Bone density technicians worldwide are going to start asking questions,” said Dr. Silverman, an attending physician in the division of rheumatology at Cedars-Sinai Medical Center in Los Angeles.

“You will get a printout that says your patient has, [for example], a 10-year risk of hip fracture of 3%,” he said.

The calculated 10-year risk for clinical fracture of the shoulder, forearm, or vertebra will also be included in a separate score.

Factors in the 10-year predictions of fracture risk include:

▸ Age, which can change the 10-year risk for a woman with a T score of −2.5 at the femoral neck from 2% at age 50 to 12.5% at age 80.

▸ History of prior fragility fracture, which increases fracture risk fivefold.

▸ Low body weight/BMI.

▸ History of a hip fracture in the patient's mother or father.

▸ Lifetime history of ever using corticosteroids at a dose of 5 mg/day or greater for 3 months or longer.

▸ Current smoking.

▸ Consumption of more than two alcoholic drinks per day.

▸ Secondary osteoporosis caused by a disease process or a drug such as an aromatase inhibitor.

In part, the new international guidelines were driven by pragmatism, because not every country has wide availability of DXA machines, and even when they are accessible, “bone mass is only a snapshot in time,” said Dr. Silverman, who is also from the University of California, Los Angeles.

Factoring in other criteria that are found to influence fracture rates may prove to be more accurate and clinically useful to all physicians, not just those in China, where there are 300 DXA machines and more than 1 billion people. By comparison, there are 20,000 DXA machines and 300 million people in the United States.

“For a long time, the message you've been getting … is that your responsibility as a physician is reducing the risk of osteoporosis. We're not in that mode any more,” he said.

“Your goal is not to reduce risk of osteoporosis, but to reduce the risk of fracture,” he emphasized.

In the general population, only half of the people who fracture also have osteoporosis.

Strategies should focus not only on that 50%, but also on the other 50% of people who have only osteopenia or low bone mass and may be unaware of their risk.

One way in which risk can be reduced is through vitamin D supplementation recommendations, which are also likely to change soon, according to Dr. Silverman.

“Recently, we have all come to appreciate that we really need much more vitamin D,” he said.

“We're pushing for 800 to 1,000 IU day, and I will tell you that a lot of us in the field … are actually taking more than that.”

Findings from new studies show that vitamin D is useful not only for bones, but also for balance and possibly for reducing overall cancer risk, he noted.

FAMILY PRACTICE NEWS is published by the International Medical News Group, a division of Elsevier.