Beyond bone mineral density, FRAX-based tailor-made intervention thresholds for therapeutic decision in subjects on glucocorticoid

Abstract

Glucocorticoid-induced osteoporosis (GIOP) is the most common cause of secondary osteoporosis and confers a substantial risk for future fractures. Several recent guidelines for GIOP management have recommended the use of intervention thresholds to direct pharmacological therapy in those at high risk of fracture. The aim of this study was to analyze the characteristics of subjects on a glucocorticoid (GC) and to implement the Fracture Risk Assessment Tool (FRAX)-based intervention threshold for therapeutic decision-making.This was a cohort substudy of a nationwide osteoporosis screening program conducted in Taiwan from 2008 to 2011. All participants were requested to complete a questionnaire including FRAX elements, and antiosteoporosis medication (AOM) history was assessed before bone mineral density (BMD) measurement. GC users were recruited as the study group. Controls comprised randomly selected age- and sex-matched non-GC users. Individual intervention threshold (IIT) was set at individual-specific FRAX probability of a major osteoporotic fracture, relative to subjects with prior fractures. The characteristics and calculated IIT of all participants were analyzed.A total of 8704 participants were enrolled, including GC users (n = 807) and controls (n = 7897). There was no significant difference in BMD between GC users and controls. Clinical fracture risks, including previous fracture, parental hip fracture, rheumatoid arthritis, and secondary osteoporosis were higher in GC users than in controls. GC users had a higher 10-year probability of either major or hip fracture than controls. The proportion of GC users with a 10-year probability of major osteoporotic fracture above IIT was higher than in controls (75.0% vs 10.6%; P < 0.001). Only 20.3% of GC users and 30.5% of controls whose fracture risk was above IIT reported taking AOM.These findings suggest that more GC users should receive active intervention based on IIT, regardless of BMD. However, less than one-fourth of GC users whose fracture risk was above IIT received AOM, indicating that GIOP is markedly undertreated. We recommend commencing AOM for GIOP according to IIT, instead of BMD alone.

The Impact of Low-Dose Glucocorticoids on Disease Activity, Bone Mineral Density, Fragility Fractures, and 10-Year Probability of Fractures in Patients with Rheumatoid Arthritis

“… 14 We modified the calculation of individual intervention threshold (IIT) by inputting gender, body weight, and body height and assumed that the participant had a ‘prior fracture’ but no other risk factors and BMD unavailable. 15 Then, we recalculated the individual-specific 10-year probability of major fracture of that participant by inputting the real situation. We defined ‘above IIT’ as 10-year probability of major fracture of that participant being higher or equal to IIT of the same participant.…”

Дискусійні Питання Визначення Порога Втручання При Глюкокортикоїдіндукованому Остеопорозі: Кого Лікувати?

“…A woman of 65 years old, with rheumatoid arthritis, a low BMI and a history of falls and fractures who took a daily GC dose of 15 mg (a general fracture risk of 54) had a 5-year fracture risk of 47 % (while a man with a similar case record -30.1 %). A short-term high-dose GC treat- Within the framework of an all-national program of osteoporosis screening, a cohort study was held in Taiwan from 2008 to 2011; its findings having been published in 2017 [65]. The study was aimed at developing and implementing the threshold intervention standards, based on FRAX ® , for the GC patients.…”

“…However, only 20.3 % of the GC treated and 30.5 % of controls, whose fracture risk exceeded the IIT, reported taking anti-osteoporotic treatment. The researchers concluded the GC users should receive an active treatment according to their IIT, and not according to the BMD [65].…”

Advances in treatment of glucocorticoid-induced osteoporosis

“…However, the BMD used in the FRAX tool is the femoral neck, while GIO more heavily affects sites with more trabecular bone such as the lumbar spine, so FRAX will underestimate the probability of fracture. Corroborating this, a study in Taiwan noted that glucocorticoid users have a higher probability of major osteoporotic fracture regardless of bone mineral density [26]. Furthermore, FRAX cannot be used in people less than 40 years of age, so clinical judgment is required.…”