Learning objective
- •
Integrate clinical findings, DXA scan results, FRAX results, and NOF guidelines to develop a management strategy tailored to the individual needs of the particular patient concerned.
The case study
Reason for seeking medical help
- •
CA, 67 years old, had a DXA scan done 2 weeks ago. She is referred for management of her bone health.
Past medical/surgical history
- •
Natural menopause at 48 years, started Hormonal Replacement Therapy (HRT) but discontinued it a few months later because of adverse effects.
Lifestyle
- •
Daily calcium intake, estimated at about 1200 mg.
- •
Does not smoke cigarettes.
- •
Consumes alcoholic drinks in moderation, not exceeding three drinks a week.
- •
Drinks neither coffee nor soda drinks.
- •
Sedentary lifestyle.
Medication(s)
- •
Multivitamin tablets once a day.
Family history
- •
Negative for osteoporosis.
Clinical examination
- •
Weight: 178 pounds, height 5′4″.
- •
Mild kyphosis.
- •
Lying BP 144/89, pulse 78/min; standing blood pressure 140/82, pulse 91/min, regular, no orthostasis.
- •
Mild osteoarthritic changes affecting both knees. No difficulties standing up. Gait steady.
- •
No clinical evidence of localizing neurological lesions, no peripheral neuropathy.
- •
No heart failure, no cervical spondylosis, and no sensitive carotid sinus.
- •
Timed Get-Up-and-Go test completed in 10.4 s.
Laboratory result(s)
- •
About 2 weeks prior to visit she had a number of laboratory tests done as part of her annual physical examination. All results were within the normal limits, including complete blood count (CBC), comprehensive metabolic panel (CMP), serum 25-hydroxy-vitamin D level, and serum thyroid stimulating hormone (TSH).
| Bone site | BMD | T-scores |
|---|---|---|
| Right femoral neck | 0.652 | −1.7 |
| Right total hip | 0.875 | −0.6 |
| Left femoral neck | 0.621 | −2.1 |
| Left total hip | 0.852 | −0.7 |
| L1–L4 | 0.645 | −1.8 |
FRAX Scores (10-year probability of fracture):
Hip fracture risk: 4.2%: EXCEEDED
Other major fractures risk: 28%: EXCEEDED
National Osteoporosis Foundation threshold for initiating treatment: REACHED
Vertebral Fracture Assessment: Not needed/not done
Multiple choice questions
- 1.
In CA’s case, the following is/are correct:
- A.
The densitometric diagnosis is osteopenia.
- B.
The FRAX scores (10-year probability of sustaining a hip or major fracture) exceed the USA-NOF threshold for considering treatment.
- C.
Pharmacologic management is recommended.
- D.
A and C.
- E.
A, B, and C.
Correct answer: E
Comment:
CA has densitometric evidence of osteopenia (the lowest T-score is −2.1 in the lumbar vertebrae, less than −1.0, but higher than −2.5). Her FRAX score, i.e., her probability of sustaining a major osteoporotic or hip fracture in the next 10 years (28% and 4.2% for the risk of an osteoporotic major or hip fracture, respectively), exceeds the threshold recommended by the US-National Osteoporosis Foundation to initiate pharmacologic treatment (3% for hip fracture and 20% for other major osteoporotic fractures).
The goal of managing this patient therefore is to treat the low bone mass as if she had osteoporosis, even though she does not have densitometric evidence of osteoporosis. The risk of sustaining fracture(s) in the next 10 years, as per the FRAX algorithm, overrides the densitometric diagnosis.
- A.
- 2.
The FRAX algorithm:
- A.
Estimates the patient’s 5- and 10-year probability of sustaining a hip or major osteoporotic fracture.
- B.
Can be applied without including the patient’s BMD or T-score.
- C.
Can be applied to men aged 40 to 90 years.
- D.
A, B, and C.
- E.
B and C.
Correct answer: E
Comment:
The FRAX algorithm was developed under the auspices of the World Health Organization and first launched in 2008. It estimates the probability of the patient sustaining a hip or major osteoporotic fracture within the next 10 years. The permutation can be done with or without the BMD/T-score of the femoral neck. It is available free of charge on the web and has undergone several revisions. FRAX can be applied to men and women between the ages of 40 and 90 years.
- A.
- 3.
The FRAX algorithm:
- A.
Considers the BMD/T-scores of the lumbar vertebrae, total hip, or femoral neck.
- B.
Grades risk factors into three categories: mild, moderate, and severe.
- C.
Considers the patient’s risk of falling.
- D.
All of the above.
- E.
None of the above.
Correct answer: E
Comment:
The FRAX algorithm has several limitations including ignoring the BMD of the lumbar vertebrae, one of the first bones to be affected by bone demineralization, and a number of factors that predispose to falls and therefore increase the fracture risk. Furthermore, the answer to all the questions related to risk factors is binary and therefore can only be answered as yes/no. It is therefore not possible to grade these responses; consequently, in the FRAX permutation, there is no difference if the patient is on 2-mg or 40-mg prednisone daily. It also does not consider the patient’s daily calcium intake and whether or not she has hypovitaminosis D. Similarly, the risk of falling is not included in the FRAX permutation. Finally, pathologies such as arthritis, muscle weakness, orthostatic hypotension, cardiac arrhythmias, vertebrobasilar insufficiency which also affect the risk of falling and fracturing are not included in the permutation. Falls and fractures are discussed in a different case study.
- A.
- 4.
In CA’s case, the FRAX scores:
- A.
Underestimate the true fracture risk.
- B.
Overestimate the true fracture risk
- C.
Can be used to monitor her response to therapy.
- D.
A and C.
- E.
B and C.
Correct answer: A
Comments:
FRAX considers the patient’s age, gender, weight, and height in addition to the presence or absence of seven risk factors: a history of fractures, a history of hip fracture in one of the biologic parents, glucocorticoid intake, rheumatoid arthritis, current cigarette smoking, alcohol abuse, and secondary osteoporosis.
FRAX does not consider factors that increase the risk of falls such as diabetes mellitus, autonomic neuropathy, Parkinson’s disease, orthostatic hypotension, arthropathies, and medications, apart from prednisone, that can induce bone demineralization. It therefore underestimates the risk of fractures in these patients. FRAX cannot be used if the patient is receiving pharmacologic therapy for osteoporosis and therefore cannot be used to monitor the patient’s response to therapy.
- A.
- 5.
The Garvan fracture risk calculator (FRC) considers the following:
- A.
Number of falls sustained in the previous 12 months.
- B.
Number of fragility fractures sustained.
- C.
BMD of the lumbar vertebrae or femoral neck.
- D.
A and B.
- E.
A, B, and C.
Correct answer: E
Comment:
The Garvan FRC estimates the 5- and 10-year probability of sustaining a fracture in women and men aged 60 years and older. It considers the BMD of the lumbar vertebrae or femoral neck, the patient’s age and weight, and the number of falls sustained during the previous 12 months stratified into 1 and 2 or more than 2 falls. The number of fragility fractures sustained is also stratified into 1, 2, and more than 2.
- A.
- 6.
The Timed Get-up-and-Go test:
- A.
Is the time taken by the patient to stand up from the sitting position without using the arms of the chair.
- B.
Reproducibility and interrater and intrarater variability are very good.
- C.
The risk of sustaining a fall is increased if the test is completed in more than 14 s.
- D.
A and B.
- E.
A, B, and C
Correct answer: B
Comment:
The Timed Get-up-and-Go test is the time taken by the patient to get up from a chair without using arm rests, walk 10 ft, and return to sit on the chair. The patient uses regular footwear and may use a walking aid. The interrater and intrarater variability is very good. Although controversial, it is accepted that the risk of falling, and therefore of fracture, is increased if the test is not completed within 14 s.
- A.
- 7.
The QFracture score:
- A.
Is based on clinical risk factors.
- B.
Includes results of three blood tests: a complete blood picture and comprehensive metabolic profile.
- C.
Includes information about alcohol intake.
- D.
None of the above.
- E.
All of the above.
Correct answer: A
Comment:
The QFracture scale is a 10-year risk algorithm for the patient sustaining a fragility fracture. It is limited to clinical risk factors affecting the fracture risk and is based on data from the UK. One of its main advantages is that it can be calculated entirely based on information available in the patient’s clinical records, therefore facilitating retrospective data collection.
- A.
- 8.
The following is/are true concerning the risk of fractures:
- A.
Most patients who sustain fragility fractures have densitometric evidence of osteoporosis.
- B.
Most patients who sustain fragility fractures have densitometric evidence of osteopenia.
- C.
The fracture risk of all patients with osteopenia is about the same.
- D.
A and C.
- E.
B and C.
Correct answer: B
Comment:
The majority of patients who sustain osteoporotic fractures have densitometric evidence of osteopenia and not osteoporosis. Intuitively, the fracture risk of a patient who has a T-score of −1.1 is much lower than that of a patient who has a T-score of −2.4 and yet, both are in the same densitometric diagnostic category: osteopenia. In these patients it is therefore important to evaluate the patient’s fracture risk in order to develop a management strategy tailored to the individual circumstances of the patient. In this respect the FRAX algorithm is quite useful as it adds a different dimension to fracture risk assessment.
- A.
- 9.
Bone mineral density is:
- A.
The single most important factor affecting fracture risk.
- B.
For each standard deviation below that of a normal reference population, fracture rate is about doubled.
- C.
In treated patients, medication induced increases in BMD account for most of the fracture risk reduction.
- D.
A and B.
- E.
A, B, and C.
Correct answer: D
Comments:
It has long been known that the bone mineral density is the single most important factor affecting fracture risk: for each standard deviation below the mean of the reference population, the fracture risk is about doubled. BMD, however, is not the only factor affecting fracture risk, and changes in bone density account for less than half the reduction in fracture risk induced by medications to treat osteoporosis. Several other factors apart from BMD modulate the risk of fractures and are discussed in other case studies.
- A.
- 10.
The following affect the fracture risk, independently of the BMD:
- A.
Hip axis length.
- B.
Femoral neck angle.
- C.
Markers of bone resorption.
- D.
All of the above.
- E.
None of the above.
Correct answer: D
Comments:
The longer the hip axis length is, the more susceptible it is to fracture after being subjected to trauma. Similarly, the less acute the femoral angle is, the more likely it is fracture. These differences may explain the different fracture risks of different ethnic groups.
- A.
Case summary
Analysis of data
Factors predisposing to bone demineralization/osteoporosis
- •
Postmenopause, no HRT.
Factors reducing risk of bone demineralization/osteoporosis
- •
Good daily calcium intake.
- •
No cigarette smoking.
- •
No excessive sodium, caffeine, or alcohol intake.
Factors increasing risk of falls/fractures
- •
None, except for sedentary lifestyle.
- •
CA has not sustained any falls or near-falls.
Factors reducing risk of falls/fractures
- •
None.
- •
CA has not sustained any falls.
Diagnosis
- •
Postmenopausal osteopenia.
- •
Fracture risk exceeds threshold established by the National Osteoporosis Foundation to initiate pharmacologic management.
Management recommendations
Treatment(s)
- •
Antiresorptive medication. At this stage there is no indication for an osteoanabolic medication.
Lifestyle
- •
Exercises to increase mobility and steadiness.
DXA and radiological
- •
Repeat DXA scan in 2 years to monitor bone mass and fine-tune management strategy.
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