1. The FRAX tool for Osteoporosis Should all GP’s be calculating the Frax score prior to treatment Dr Sanjeev Patel Consultant Physician & Senior Lecturer in Rheumatology

2. Principal sites of osteoporotic fractures

3. Morbidity associated with osteoporotic fractures

4. Mechanisms of osteoporotic fractures Risk of fracture Risk of fall Force of impact Strength of bone Neuromuscular function Environmental hazards Time spent at risk Type of fall Protective responses Energy absorption Bone mineral density Geometry of bone Quality of bone

5. Determinants of fracture risk Age History of previous fracture Bone density (Falls) Others - less consistent – Family history – Smoking – Early menopause

6. Falls

7. Bone density, fall risk and age 0 20 50 65 100 Age (years) Bone density

8. Bone density, fall risk and age 0 20 50 65 100 Age (years) Bone density Fall incidence

9. Previous paradigm OP = T score = BP

10. Identification of high risk individuals What can we learn from cardiovascular disease ? Move from relative risk to absolute risk

11. CVS events compared to OP fractures CVS events Age Raised cholesterol Raised blood pressure Diabetes Smoking FH Previous MI / stroke Osteoporotic fractures Age Low bone density Secondary causes of low bone density e.g. steroids FH Increased fall risk Previous fracture

12. Absolute risk of cardiovascular events

15. Absolute fracture risk Combination of BMD (T score) Clinical risk factors e.g. previous fracture Can obtain absolute fracture risk with or without BMD data Aim to treat only those at high risk

16. Absolute fracture risk calculators FRAX International QfractureUK specific Fore US specific All calculate 10 yr absolute risk of fracture

17. FRAX http://www.shef.ac.uk/FRAX/http://www.shef.ac.uk/FRAX/

18. Example patients Woman A – Aged 60, mother has had a hip fracture – Femoral neck T score -2.5

19. National Osteoporosis Guidelines Group Treat Lifestyle advice and reassure Intervention Threshold (60 yr old woman with FH hip fracture and T score -2.5) Major Fracture - 10 year fracture probabilityHip - 10 year hip fracture probability x x 15 % 2.4 %

20. Example patients Woman A – Aged 60, mother has had a hip fracture – Femoral neck T score -2.5 Women B – Aged 80, mother has had a hip fracture – Femoral neck T score -2.5 – Patient has had a previous wrist fracture

21. National Osteoporosis Guidelines Group Treat Lifestyle advice and reassure Intervention Threshold (80 yr old woman with FH hip fracture and personal history of wrist fracture and T score -2.5) Major Fracture - 10 year fracture probabilityHip - 10 year hip fracture probability x x 30% 20 %

22. Example patients Woman A – Aged 60, mother has had a hip fracture – Femoral neck T score -2.5 Women B – Aged 80, mother has had a hip fracture – Femoral neck T score -2.5 – Patient has had a previous wrist fracture Women C – Aged 45, worried about osteoporosis – Femoral neck T score -2.5

23. National Osteoporosis Guidelines Group Treat Lifestyle advice and reassure Intervention Threshold (45 yr old woman worried about osteoporosis and T score -2.5) Major Fracture - 10 year fracture probabilityHip - 10 year hip fracture probability x x 4.8 % 1.6 %

25. QFracture 65 year old woman who is a smoker, drinks 15 units per week and is on steroids for PMR and has T2DM Your results Your 10-year risk of any osteoporotic fracture, (hip, wrist or spine), is 13%. Your 10-year risk of hip fracture is 6%. In other words, in a crowd of 100 people like you, 13 will develop osteoporotic fracture of hip, wrist or spine in the next 10 years. Similarly, 6 will develop hip fracture in the next 10 years. This is represented by the smileys below.

26. Absolute fracture risk calculator

27. Issues for discussion Relative versus absolute fracture risk Calculate fracture risk particularly for: – Primary prevention of fractures – Where you are uncertain about fracture risk – Where you want to show patients that treatment is unnecessary – To estimate drug benefit versus drug risk