What is the approach to assessing and managing fracture risk in patients with osteoporosis?

Fracture Risk Assessment and Management in Osteoporosis

The approach to assessing and managing fracture risk in osteoporosis should include an initial clinical fracture risk assessment, followed by appropriate bone mineral density (BMD) testing, risk stratification using validated tools like FRAX, and implementation of targeted pharmacological and non-pharmacological interventions based on risk level. 1

Initial Fracture Risk Assessment

Clinical Assessment

• Obtain detailed history of:
  • Glucocorticoid use (dose, duration, pattern)
  • Prior fractures (both traumatic and non-traumatic)
  • Fall history and frailty assessment
  • Family history of hip fracture
  • Alcohol consumption (≥3 units/day) and smoking status
  • Secondary causes of osteoporosis (malnutrition, significant weight loss, hypogonadism, hyperparathyroidism, thyroid disease)
  • Comorbidities affecting bone health

Physical Examination

• Measure weight and height (without shoes)
• Assess muscle strength
• Evaluate for clinical findings of undiagnosed fractures (spinal tenderness, deformity, reduced space between lower ribs and upper pelvis)

Diagnostic Testing

• For adults ≥40 years: Calculate absolute fracture risk using FRAX with BMD testing within 6 months 1
  • FRAX tool should be adjusted for glucocorticoid dose (if prednisone >7.5 mg/day, increase major osteoporotic fracture risk by 1.15 and hip fracture risk by 1.2)
• For adults <40 years: BMD testing if high fracture risk due to previous osteoporotic fracture or significant risk factors 1
• For all patients: Consider vertebral fracture assessment (VFA) or spinal x-rays to identify asymptomatic vertebral fractures 1

Risk Stratification

Risk Categories

1. Very High Risk:

   • Prior osteoporotic fracture(s)
   • BMD T-score ≤-3.5
   • High-dose glucocorticoids (≥30 mg/day or cumulative doses ≥5g/year)
   • 10-year major osteoporotic fracture risk ≥20%

2. High Risk:

   • BMD T-score ≤-2.5
   • 10-year major osteoporotic fracture risk 10-19%
   • Glucocorticoid use ≥7.5 mg/day for >3 months

3. Moderate Risk:

   • Intermediate fracture risk by FRAX
   • Z-score <-3 at hip or spine

   • 10%/year loss of BMD at hip or spine

4. Low Risk:

   • No significant risk factors
   • Low FRAX score

Management Approach

Non-pharmacological Interventions (All Patients)

• Adequate calcium intake (1000-1200 mg daily)
• Vitamin D supplementation (600-800 IU daily)
• Weight-bearing and muscle resistance exercises
• Balance exercises to prevent falls
• Smoking cessation
• Limit alcohol consumption

Pharmacological Management Based on Risk

1. Very High Risk:

   • Anabolic agents (teriparatide, abaloparatide, romosozumab) are conditionally recommended over antiresorptive agents 1, 2
   • Follow with antiresorptive therapy to maintain gains

2. High Risk:

   • Oral bisphosphonates strongly recommended (first-line due to efficacy, safety, and low cost) 1, 3
   • Alternatives: denosumab or anabolic agents if unable to tolerate bisphosphonates

3. Moderate Risk:

   • Oral or IV bisphosphonates, denosumab, or anabolic agents conditionally recommended 1

4. Low Risk:

   • Calcium and vitamin D supplementation
   • Lifestyle modifications
   • Regular monitoring

Reassessment of Fracture Risk

Timing of Reassessment

• For patients continuing glucocorticoids: Clinical fracture risk reassessment every 12 months 1
• For adults ≥40 years not on osteoporosis medication: FRAX with BMD testing every 1-3 years 1
• For adults on osteoporosis medication: BMD testing every 2-3 years 1
• For very high-risk patients: Consider more frequent monitoring (yearly BMD until stable) 1

Considerations for Treatment Duration

• Reassess need for continued therapy after 3-5 years for bisphosphonates in low-risk patients 3
• For denosumab, romosozumab, and anabolic agents, sequential treatment with antiresorptive agents is necessary to prevent rebound bone loss 1

Important Caveats and Pitfalls

1. FRAX Limitations:

   • Not validated for adults <40 years
   • Underestimates risk in patients on very high-dose glucocorticoids
   • Does not adequately account for frailty, multiple fractures, or fall history 1
   • May not accurately reflect risk reduction with treatment, though it remains valuable for guiding continued treatment decisions 4

2. Imminent Fracture Risk:

   • Fracture risk is highest in the 1-2 years following a major osteoporotic fracture 1
   • This "imminent fracture risk" requires prompt intervention

3. Treatment Gaps:

   • Despite available assessment tools and effective treatments, approximately 70% of high-risk patients do not receive appropriate assessment and treatment 1
   • Implement fracture liaison services to improve identification and treatment of high-risk patients

4. Special Populations:

   • Patients with glucocorticoid-induced osteoporosis require specific risk assessment and management approaches 1
   • Consider organ transplant recipients, pregnant women, and children separately

By implementing this structured approach to fracture risk assessment and management, clinicians can effectively identify patients at risk for osteoporotic fractures and provide appropriate interventions to reduce fracture risk and associated morbidity and mortality.