Diagnostic criteria for osteoporosis should be expanded

Abstract

As a relatively newly classified chronic disease, scientific enquiry about pathophysiology, diagnosis, and treatment for osteoporosis has rapidly increased in the past three decades. Under the direction of the National Bone Health Alliance, a working group has proposed expansion of the diagnostic criteria for osteoporosis in men and postmenopausal women aged 50 years and older to include individuals with any of the following: a hip fracture (with or without bone mineral density [BMD] testing); low bone mass as determined by BMD and a vertebral, proximal humeral, pelvic, or, in some cases, distal forearm fracture; or raised fracture risk based on the WHO fracture risk algorithm, FRAX. We propose that this is a prudent approach and that it reflects the present understanding of bone fragility and fracturerisk prediction.With the emergence of bone densitometry as a reliable measure, in 1994 WHO proposed the first operational definition of osteoporosis based on BMD T-scores. 1 These criteria were established based on dual-energy X-ray absorptiometry (DXA) as the technique to quantify bone mass. 2 Given that the diagnostic cut-point for osteoporosis (more than 2·5 standard deviations below the young average value) is based on a statistical distribution, the absolute BMD values for osteoporosis diagnosed in this way differ according to the site measured, technique, equipment, and reference population.In the past decade, there have been at least two paradigm shifts in the diagnosis and management of osteoporosis. The first major shift was the incorporation of clinical risk factors into fracture risk prediction. The FRAX tool developed by WHO, which can be used to predict fracture risk with or without BMD values, has been validated worldwide. Since 2010, Canadian osteoporosis guidelines have incorporated clinical risk factors for diagnosis of osteoporosis in addition to BMD, 3 similar to other countries. 4 Individuals at high risk of fractures are those with previous fracture of the hip or spine, more than one previous nonvertebral fracture (excluding hands, feet, and ankles), or those who have recently used glucocorticoids and have had one previous fracture. Numbers needed to treat to prevent further fractures are low and intervention is cost-effective in these high-risk individuals. 3 The second shift has been recognition of the importance of bone quality, in addition to density, as a key component of bone strength. Bone quality can be thought of as a complex set of interdependent factors that affect bone strength, including structural (eg, geometry and CIHR Author ManuscriptCIHR Author Manuscript CIHR Author Manuscript microarchitecture) and material (eg, mineral crystal size, quality of collagen, and microdamage or microfracture) properties of bone. 5 Although the use of bone quality measures in clinical diagnosis of osteoporosis is still being investigated, several techniques can be used to estimate bone quality.These shifts are based on the concept that BMD alone does not adequately predict fracture risk. Relative...

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