Our goal is NO NEW FRACTURES. Cancellous (spongy, like the ends of the drumstick) bone should be a strong latticework of struts called trabeculi. Clinical Osteoporosis, an increased fracture risk, occurs when some of the struts disappear.
Trabecular Bone Score (TBS) evaluates the spongy bone in the DXA images of the vertebrae (spine) looking for irregularities. When TBS finds uneven bone mineral density within the spine DXA, that indicates a higher fracture risk, regardless of the total BMD.
Adding the TBS feature to a DXA machine allows the quality of bone in the spine to influence the FRAX score, just like the BMD in the femoral neck part of the hip influences the FRAX score. Adding TBS detects more patients at high fracture risk who should be treated to avoid fractures.
Diabetes increases a person’s fracture risk for any given DXA BMD or T-score. Controlled diabetes adds about the same risk as rheumatoid arthritis, so we usually check that box in FRAX. Uncontrolled diabetes is more serious requiring further adjustment to FRAX.
FRAX is pre-empted by a hip fracture. “Do not pass GO, do not collect $200, start a pharmaceutical” Vertebral (spine) Fracture is the same, but the majority of spine fractures are not noticed clinically. “Morphometric” (first noticed on x-ray) vertebral fractures count, but how to find them?
VFA next time
Jay Ginther, MD
Our Target is NO NEW FRACTURES. The original goal by DXA was a T-score of -2.4 or better. But age is a huge factor in actual fracture risk. The fracture risk of a T-score of -2.5 at age 60 is the same as a T-score of -3.1 at age 50, is the same as a T-score of -1.3 at age 80.
FRAX was developed by WHO and the International Osteoporosis Foundation to take age and other factors into account. The big 5 risk factors are age, previous fracture, parental hip fracture, smoking, and oral or inhaled corticosteroids. Rheumatoid arthritis (or diabetes), over 3 doses of alcohol daily, and BMI < 19 or > 35 also count. Male and Female are different. Femoral Neck of the hip BMD by DXA is only 30% of the calculation when available.
Treat to Target by FRAX is a “Major Osteoporotic” (wrist, shoulder, hip or clinically noticed spine) Fracture Risk of < 20%. Alternately a Hip Fracture Risk of < 3.0 is the target. FRAX identifies a more individualized fracture risk than DXA with or without fragility fracture.
Look up the FRAX tool at http://www.sheffield.ac.uk/FRAX/
FRAX gives different targets than DXA because it takes additional risk factors into account. And there have been some refinements added.
Jay Ginther, MD
Treat to Target means aiming for NO NEW FRACTURES. As discussed last time, the original target was to maintain Bone Mineral Density (BMD) at the level first tested. 25 years ago that was amended to be a T-score of -2.4 or higher, since “osteoporosis the test result” was set at -2.5.
But what if you already have fractured? Clinical Osteoporosis the diagnosis is a T-score of -1.5 plus a “Fragility Fracture” acquired in any fall from standing height, even on ice. That is because for the first year after a fracture your risk is 5 times normal. Your risk decreases to 2 times normal after 5 years, but always is higher after a fragility fracture.
If your Fragility Fracture was a Hip Fracture, you have Clinical Osteoporosis regardless of DXA BMD and T-score. You are at high risk of future fracture, especially of the other hip. You should start treatment to prevent a new fracture. At the very least you need to optimize calcium, vitamin D3, protein, and multiple vitamins & minerals intake.
If you also need a pharmaceutical, it should be one which can raise your T-score above -2.5 if you have no fractures, and above -1.5 if you already have a fracture. That usually means considering an anabolic. Your goal is NO NEW FRACTURES.
FRAX next time.
Jay Ginther, MD
Once again we have been treated to statisticians mushing together multiple disparate previous studies to “prove” that calcium alone, or vitamin D alone, or both together in one of many different combinations will not prevent fractures. All mushed together in a carefully selected meta-analysis, you can prove anything depending on which studies are included.
More important, asking if adding a specific dose of calcium, or vitamin D, or both, will prevent fractures, misses the entire point. Most studies did not properly account for the nutrients in each day’s diet in individual test subjects – or in individual control subjects, many of whom also consumed the nutrients being studied.
And how can you ethically ask a patient to limit their diet in a way you believe will put them at risk for fractures? You have to settle for encouraging patients who are inadvertently short on some nutrients to improve their diet. But then they do not fracture and you cannot prove that they would have if only you had withheld the information!
We help individuals improve their bone health. One size does not fit all. We do a Complete Bone Health Evaluation. Then we adjust nutrition and lifestyle as needed for that individual. In about half of women and three-quarters of men, this is enough.
Jay Ginther, MD