Case finding for the management of osteoporosis with FRAX®—assessment and intervention thresholds for the UK
- 1.5k Downloads
Assessment and intervention thresholds are developed and proposed in men aged over 50 years and postmenopausal women for the UK based on fracture probability from the WHO fracture risk assessment tool (FRAX®).
The FRAX® tool has recently become available to compute the 10-year probability of fractures in men and women from clinical risk factors (CRFs) with or without the measurement of femoral neck bone mineral density (BMD). The aim of this study was to develop a case-finding strategy for men and women from the UK at high risk of osteoporotic fracture by delineating the fracture probabilities at which BMD testing or intervention should be recommended.
Fracture probabilities were computed using the FRAX® tool calibrated to the epidemiology of fracture and death in the UK. The relationship between cost effectiveness and fracture probability used the source data from a prior publication that examined the cost effectiveness of generic alendronate in the UK. An intervention threshold was set by age in men and women, based on the fracture probability equivalent to that of women with a history of a prior osteoporosis related fracture. In addition, assessment thresholds for the use of BMD testing were explored. Assessment thresholds for the measurement of BMD followed current practice guidelines where individuals were considered to be eligible for assessment in the presence of one or more CRF. An upper assessment threshold (i.e. a fracture probability above which patients could be treated without recourse to BMD) was based on optimisation of the positive predictive value of the assessment tool. The consequences of assessment and intervention thresholds on the requirement for BMD test and interventions were assessed using the distribution of clinical risk factors and femoral neck BMD for women in the source cohorts used for the development of the FRAX® models
Treatment was cost effective at all ages when the 10-year probability of a major fracture exceeded 7%. The intervention threshold at the age of 50 years corresponded to a 10-year probability of a major osteoporotic fracture of 7.5%. This rose progressively with age to 30% at the age of 80 years, so that intervention was cost effective at all ages. Assessment thresholds for testing with BMD (6–9% at the age of 50 years) also rose with age (18–36% at the age of 80 years). The use of these thresholds in a case-finding strategy would identify 6–20% of women as eligible for BMD testing and 23–46% as eligible for treatment, depending on age. The same threshold can be used in men.
The study provides a method of developing management algorithms for osteoporosis from the estimation of fracture probabilities, rather than those based on BMD alone or BMD with single or multiple CRFs.
KeywordsAssessment thresholds BMD Clinical risk factors Fracture probability FRAX® Intervention thresholds Osteoporotic fracture
The National Osteoporosis Guideline Group thanks the WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield and the International Osteoporosis Foundation for supporting the meetings of NOGG.
Conflicts of interest
- 1.Royal College of Physicians (1999) Osteoporosis: clinical guidelines for the prevention and treatment 1999. Royal College of Physicians, LondonGoogle Scholar
- 2.Royal College of Physicians and Bone and Tooth Society of Great Britain (2000) Update on pharmacological interventions and an algorithm for management 2000. Royal College of Physicians, LondonGoogle Scholar
- 3.Royal College of Physicians (2002) Glucocorticoid-induced osteoporosis. Guidelines on prevention and treatment. Bone and Tooth Society of Great Britain, National Osteoporosis Society and Royal College of Physicians. Royal College of Physicians, LondonGoogle Scholar
- 5.Kanis JA, Burlet N, Cooper C, Delmas PD, Reginster J-Y, Borgstrom F, Rizzoli R, European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) (2008) European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 19:399–428PubMedCrossRefGoogle Scholar
- 6.European Community (1998) Report on osteoporosis in the European Community. EC, StrasbourgGoogle Scholar
- 12.Committee for Medicinal Products for Human Use (CHMP) (2006) Guideline on the evaluation of medicinal products in the treatment of primary osteoporosis. Ref CPMP/EWP/552/95Rev.2. London, CHMP. Nov 2006Google Scholar
- 20.Kanis JA, on behalf of the World Health Organization Scientific Group (2008) Assessment of osteoporosis at the primary health-care level. Technical Report. WHO Collaborating Centre, University of Sheffield, UKGoogle Scholar
- 23.Stevenson M, Lloyd Jones M, De Nigris E, Brewer N, Davis S, Oakley J (2005) A systematic review and economic evaluation of alendronate, etidronate, risedronate, raloxifene and teriparatide for the prevention and treatment of postmenopausal osteoporosis. Health Technol Assess 9:1–160PubMedGoogle Scholar
- 26.Kanis JA, Stevenson M, McCloskey EV, Davis S, Lloyd-Jones M (2007) Glucocorticoid-induced osteoporosis: a systematic review and cost-utility analysis. Health Technol Assess 11:1–256Google Scholar
- 27.National Institute for Clinical Excellence (2004) Guide to the methods of technology appraisal. Abbo Litho Sales, LondonGoogle Scholar
- 28.National Institute for Health and Clinical Excellence (2007) Final appraisal determination. Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. NICE, LondonGoogle Scholar
- 33.National Osteoporosis Foundation (NOF) (2003) Physician’s guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation, Washington, DCGoogle Scholar
- 38.Borgström F, Ström O, Kanis JA (2008) What proportion of patients can be treated with second line at a maintained incremental cost utility ratio. Osteoporos Int 19(Suppl 1):S65Google Scholar
- 40.Food and Drug Administration (1994) Guidelines for preclinical and clinical evaluation of agents used in the prevention or treatment of postmenopausal osteoporosis. Division of Metabolism and Endocrine Drug Products, RockvilleGoogle Scholar
- 45.McCloskey EV, Beneton M, Charlesworth D, Kayan K, deTakats D, Dey A et al (2007) Clodronate reduces the incidence of fractures in community dwelling elderly women unselected for osteoporosis: results of a double-blind, placebo-controlled randomized study. J Bone Miner Res 22:135–141PubMedCrossRefGoogle Scholar
- 52.McCloskey EV, Johansson H, Oden A, Aropuu S, Jalava T, Kanis JA (2007) Efficacy of clodronate on fracture risk in women selected by 10-year fracture probability. J Bone Miner Res 22(Suppl 1):S46Google Scholar
- 54.Johansson H, Kanis JA, Oden A, Johnell O, McCloskey EV (2008) BMD, clinical risk factors and their combination for hip fracture prevention. UnpublishedGoogle Scholar