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Menopause Live - IMS Updates
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Date of release: 19 July, 2010

The fragile-bone dispute


No one would argue with the concept that a person suffering a low-trauma hip/femur neck fracture has osteoporosis and needs therapy to prevent future fractures. But does this apply to a relatively young patient with a low-trauma radius fracture? Should we automatically diagnose and treat this patient in a similar way? It is actually a difficult question to answer in haste. The current debate started with a study from Norway [1] that examined cases of distal radius fractures (218 men, 1576 women, age > 50 years). The authors concluded that, because a large proportion of these patients, who also had a high 10-year fracture risk calculated by the WHO assessment tool FRAX(R), did not have osteoporosis by bone mineral density (BMD) criteria, all distal radius fracture patients above the age of 50 years should be routinely referred for BMD testing; only those with low bone mass should be offered medical treatment.


 


A group of key-opinion bone experts representing the International Osteoporosis Foundation and the National Osteoporosis Foundation now defy these conclusions in a short, but angry manuscript placed in the same journal [2]. They put forward the following known key points: (1) bone density measures only one of several important factors that contribute to skeletal fragility; (2) individuals with osteopenia may fracture, whereas others with a T score lower than -2 or even -2.5 standard deviations (SD) may never fracture; (3) in fact, most fractures occur in those who do not have a T score in the osteoporosis range. The authors claim that, since fragility fracture is the very definition of osteoporosis, there is no need for any further tests or surrogate markers to prove it. The conclusion of the group was that they disagree with the notion that a densitometric threshold for treatment should be applied to patients over age 50 years who suffer low-trauma distal radius fracture.

Comment

When I was a student, osteoporosis was diagnosed only when a low-trauma fracture occurred. Simple skeletal radiographs, although not accurate, served as a complementary means for detection of osteoporosis. The bone densitometry era was revolutionary in this respect, since it provided a good estimate for fracture risk even before it occurred, using a non-invasive and very safe technology. Implementation of routine BMD screening of middle-aged and elderly populations led to the identification of large numbers of people with low bone mass. It then became essential to decide on a BMD cut-off point that will serve as a guide for clinicians when making a decision on treatment. Although a BMD value lower than -2.5 SD has been generally accepted as the densitometric criterion for osteoporosis, in some countries, perhaps due to a greater influence by the pharma industry on medical societies, the set point was elevated to -2 SD, which meant that many more patients were considered as being at a higher risk and therefore becoming eligible candidates for therapy. With time, the pendulum swayed a little backward, when elaborated tools for the assessment of fracture risk were incorporated into the decision-tree algorithms for the treatment of osteoporosis. This reflected a downgrading of the central role of BMD measurements as a sole determinant in the recommendations for treatment, allowing a much more individual, tailored approach which has been based on several additional (medical) historical and clinical parameters. 
 
But now, Blank and colleagues [2] suggest a real turn-around, which puts everything back to square one. Whenever a low-trauma fracture occurs, no matter its location, there is no need for any other information in order to diagnose osteoporosis and initiate treatment. Seventeen percent of women aged 50 years will suffer a radius fracture during their remaining life [3]. I guess it would be difficult to verify that a certain radius fracture was truly a low-trauma fracture. Also, I do not know what would be the absolute reduction in risk for vertebral or hip fractures in healthy middle-aged women with densitometric, mild to moderate osteopenia who are about to receive long-term treatment because they suffered a radius fracture. Once again, we face a common situation with several possible modes of operation. Some physicians will be more aggressive and prescribe therapy to all, while others will use various assessment tools before making individual treatment decisions.

Comentario

Amos Pines
Department of Medicine T, Ichilov Hospital, Tel-Aviv, Israel

    References

  1. Oyen J, Gjesdal CG, Brudvik C, et al. Low-energy distal radius fractures in middle-aged and elderly men and women the burden of osteoporosis and fracture risk: A study of 1794 consecutive patients. Osteoporos Int 2009 Oct 8. Epub ahead of print.
    http://www.ncbi.nlm.nih.gov/pubmed/19813045

  2. Blank RD, Bilezikian JP, Bonnick SL, et al. "Evidence-based" or "logic-based" medicine? Osteoporos Int 2010 May 13. Epub ahead of print.
    http://www.ncbi.nlm.nih.gov/pubmed/20464543

  3. van Staa TP, Dennison EM, Leufkens HG, Cooper C. Epidemiology of fractures in England and Wales. Bone 2001;29:517-22.
    http://www.ncbi.nlm.nih.gov/pubmed/11728921