Posts Tagged ‘FRAX’
Knowing how to move safely avoids unnecessary risks for falls and fractures. That can improve your life. Avoid unnecessary risks.
NOF publication https://www.nof.org/wp-content/uploads/Safe-Movement-Brochure-COMBINED.pdf details proper bending, lifting, etc.
This brochure also tells how FRAX, VFA, TBS all improve the predictive power of DXA and BMD alone about who is at risk for fracture. It also visually shows the 50% risk of fracture without antiresorptive treatment compared to the 0.017% risk of unusual fractures of jaw or femur with treatment.
Read the brochure. If you need coaching for safe movement, Cedar Valley Physical Therapy can help. Choose from 4 locations: 125 E Tower Park Dr, Waterloo – 319-232-6339; 1631 Logan Ave, Waterloo – 319-232-2630; UNI, 2351 Hudson Rd, Cedar Falls – 319-273-5265; 4612 Prairie Parkway, Cedar Falls.
Avoid unnecessary risks.
Jay Ginther, MD
Diet and exercise are not always enough to prevent fractures. Medications are needed if you are fracturing or BMD is falling despite your best efforts. We have many posts about when medications should be considered and the differences among medications.
Traditionally DXA and BMD had been the main determinant of bone health. Relying solely on BMD often lead us astray. FRAX helps correct for factors other than BMD. VFA, looking at the lateral spine, often finds patients with unrecognized crumbling of the spine. TBS can be added to DXA to identify bone quality issues missed by DXA and BMD alone.
NOF has 16 pages of information at https://cdn.nof.org/wp-content/uploads/Bone-Basics_Osteoporosis-Medicines-FINAL-6.12.19.pdf
Picking the best medication for you personally requires a complete bone health evaluation and consultation with your healthcare professional.
Jay Ginther, MD
Our goal is NO NEW FRACTURES. Therefore, Treat to Target means a FRAX score of <20% for “major osteoporotic” and <3% for hip fracture. Alternately, T-score of better than -1.5 if there are any fractures.
Antiresorptives do not substantially increase bone mass or BMD. While a 3-5% BMD improvement can be seen when a long term deficiency in calcium absorption is corrected, the function of an antiresorptive is to maintain current bone mass.
If you want to substantially increase bone mass, you must use an anabolic medication. We now have 2. Forteo (teriparatide) has been available for 15 years. Tymlos (abaloparatide) was approved late last spring, but has only achieved good coverage by a majority of insurance companies in the last month.
Both can be given for up to 24 months. Both must be followed by an antiresorptive to avoid loss of gains. Both will show continued improvement in BMD for up to 3 years after switching to an antiresorptive because calcium takes up to 3 years to fully accumulate in new bone matrix formed by an anabolic.
Both should NOT be given to anyone with open growth plates, Paget’s, radiation to bone, cancers which have or could spread to bone, elevated bone specific alkaline phosphatase other than from fracture healing, or pregnant or nursing women.
Tymlos is approved for postmenopausal women only. It does not stimulate bone turnover significantly and therefore shows faster BMD increase initially in the hip. It has not been tested for use after antiresorptives.
Forteo is approved for men and women with osteoporosis which is “age-related”, or from steroid use, or from idiopathic hypogonadism. Forteo significantly increases both osteoblast and osteoclast activity, thereby stimulating bone turnover, which is often suppressed after long-term antiresorptives. Forteo is the default treatment for ONJ and AFF.
If you are dealing with vertebral fractures on VFA, or really low BMD on DXA, or with multiple fragility fractures, you need an ANABOLIC FIRST, to decrease fracture risk. Then follow with antiresorptives to maintain a low enough fracture risk.
Remember, even these medications will fail without proper nutrition.
jay Ginther, MD
Treat to Target of NO NEW FRACTURES. How do we find that target? DXA >-2.5 is a start. Fragility fractures increase new fracture risk. FRAX adds many more risk factors to the calculation and TBS refines FRAX.
Vertebral Fracture Assessment (VFA) looks at the spine from the side and independently identifies additional fracture risk. This can be done on a DXA machine or by x-ray. A single vertebral compression fracture of 25% or more pre-empts DXA, BMD, and FRAX in diagnosing Clinical Osteoporosis and recommending treatment.
VFA should be done because the majority of vertebral compression fractures are first noticed by x-ray or DXA VFA imaging. If you do not personally view the images, be sure the radiologist specifically checked for vertebral deformities as described by Genant.
I recently published my retrospective review of 1259 sequential first time VFA patients in Endocrine Practice 2017:23:1375-8.
VFA identified many patients not identified as high fracture risk (Clinical Osteoporosis) by DXA or fragility fracture or height loss or kyphosis or FRAX.
We should consider including VFA in every first time Complete Bone Health Evaluation.
And how should we treat? Next time…
Jay Ginther, MD