Newsletters

Winter 2008

FRAXTM and the New NOF Treatment Guidelines

Years in the making, the new National Osteoporosis Foundation guidelines for treatment of osteoporosis and low bone density (osteopenia) have recently been published. They were developed by Dr. John Kanis, Professor Emeritus, University of Sheffield, UK for the World Health Organization (WHO) and adapted by the National Osteoporosis Foundation for use in the United States. These guidelines take the form of an online computer tool called FRAXTM (WHO Fracture Risk Assessment tool).  The tool is still in the testing stage and the guidelines don’t substitute for physician judgment but attempt to bring some clarity to making a decision whether or not a patient should be treated with prescription medication. These guidelines are new because they use an assessment of ten-year fracture risk to aid physicians in determining if patients should be treated with medication.

Although patients with osteoporosis are at the highest risk of fracture, most fractures occur in patients who do not have osteoporosis but who have low bone density (osteopenia). This happens because there are so many more people with just low bone density. The new guidelines attempt to address this issue by using 10-year fracture risk to help us decide whether or not a patient needs to be treated.

The new guidelines take into account such factors as gender, race, age, weight, height, bone density score, personal history of fracture, family history of fracture, current smoking, corticosteroid therapy, the presence of rheumatoid arthritis, significant alcohol intake of 3 or more servings per day and any other underlying disorders strongly associated with osteoporosis such as type I diabetes, premature menopause or malabsorption. Using clinical research studies to examine the risk of fracture associated with each of the above conditions, Dr. Kanis is able to calculate an overall and hip fracture risk over the next 10 years. When the 10-year risk of any fracture is 20% or greater or the 10-year risk of hip fracture alone is 3% or greater, drug treatment is recommended. The disability caused by fractures, the cost of treating fractures and the cost and effectiveness of drug therapy in reducing fracture risk are taken into account. There are many other risk factors for fracture that are not taken into account by these guidelines that were difficult to put into the tool or did not affect the outcome of the calculation.

What we have found is that there are some patients who would have been treated with medication under the old guidelines using bone density scores and underlying risk factors alone, who now don’t qualify for treatment. Conversely, there are also some patients who may not have qualified for treatment under the old guidelines but who do qualify for treatment under the new guidelines.

It’s important to note that guidelines do not substitute for the clinical judgment of your physician. There are many circumstances that these guidelines don’t take into account. Your doctor may feel that your fracture risk is higher than the calculated risk in which case drug treatment may be recommended anyway. Although the new guidelines provide some valuable guidance they are not a substitute for physician-patient collaboration and clinical judgment in successfully treating osteoporosis or low bone density to prevent fractures. 
 

E. Michael Lewiecki, MD                                    
Lance A. Rudolph, MD

This page update 03/10/08