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. 2020 Jan;31(1):1-12.
doi: 10.1007/s00198-019-05176-3. Epub 2019 Nov 13.

Algorithm for the management of patients at low, high and very high risk of osteoporotic fractures

J A Kanis  1   2 , N C Harvey  3 , E McCloskey  4   5 , O Bruyère  6 , N Veronese  7 , M Lorentzon  8   9   10 , C Cooper  3   11 , R Rizzoli  12 , G Adib  13 , N Al-Daghri  14 , C Campusano  15 , M Chandran  16 , B Dawson-Hughes  17 , K Javaid  11 , F Jiwa  18 , H Johansson  4   8 , J K Lee  19 , E Liu  8 , D Messina  20 , O Mkinsi  21 , D Pinto  22   23 , D Prieto-Alhambra  11   24 , K Saag  25 , W Xia  26 , L Zakraoui  27 , J -Y Reginster  14   28
Affiliations

Algorithm for the management of patients at low, high and very high risk of osteoporotic fractures

J A Kanis et al. Osteoporos Int. 2020 Jan.

Erratum in

Abstract

Guidance is provided in an international setting on the assessment and specific treatment of postmenopausal women at low, high and very high risk of fragility fractures.

Introduction: The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2019. This manuscript seeks to apply this in an international setting, taking additional account of further categorisation of increased risk of fracture, which may inform choice of therapeutic approach.

Methods: Clinical perspective and updated literature search.

Results: The following areas are reviewed: categorisation of fracture risk and general pharmacological management of osteoporosis.

Conclusions: A platform is provided on which specific guidelines can be developed for national use to characterise fracture risk and direct interventions.

Keywords: Anabolic agents; FRAX; Fracture risk assessment; Inhibitors of bone resorption; Treatment of osteoporosis.

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Conflict of interest statement

NM Al-Daghri G Adib, C Campusano, M Chandran, F Jiwa, H Johansson, JK Lee, E Liu, D Pinto, N Veronese, W Xia, L Zakraoui have no conflicts of interest to declare.

O Bruyère received research grants from Biophytis, IBSA, MEDA, Servier and SMB and consulting or lecture fees from Amgen, Biophytis, IBSA, MEDA, Servier, SMB, TRB Chemedica and UCB.

C Cooper reports personal fees from Alliance for Better Bone Health, Amgen, Eli Lilly, GSK, Medtronic, Merck, Novartis, Pfizer, Roche, Servier, Takeda and UCB.

B. Dawson-Hughes has received grant support from Pfizer and DSM and consulting fees from TTY Biopharma Co, Ltd, Intrinsic Therapeutics and Agnovos.

NC Harvey has received consultancy/lecture fees/honoraria/grant funding from Alliance for Better Bone Health, Amgen, MSD, Eli Lilly, Radius Health, Servier, Shire, UCB, Consilient Healthcare and Internis Pharma.

MK Javaid has received honoraria, unrestricted research grants, travel and/or subsistence expenses from Amgen, Lilly UK, Internis, Consilient Health, Zebra Medical Vision, Kyowa Kirin Hakin and UCB.

JA Kanis reports grants from Amgen, Eli Lilly and Radius Health and consulting fees from Theramex. JAK is the architect of FRAX® but has no financial interest.

M Lorentzon has received lecture fees from Amgen, Lilly, Meda, Renapharma and UCB Pharma and consulting fees from Amgen, Radius Health, UCB Pharma, Renapharma and Consilient Health, all outside the presented work.

EV McCloskey has received consultancy/lecture fees/grant funding/honoraria from ActiveSignal, AgNovos, Amgen, AstraZeneca, Consilient Healthcare, Fresenius Kabi, Gilead, GSK, Hologic, Internis, Lilly, Medtronic, Merck, Novartis, Pfizer, Radius Health, Redx Oncology, Roche, SanofiAventis, Servier, Synexus, Tethys, UCB, Viiv, Warner Chilcott, I3 Innovus and Unilever.

OD Messina has received honoraria from Amgen, Lilly, Novartis and Pfizer

O Minski received honorary fees for lectures, from Abbvie, Roche, Pfizer, Pierre Fabre, Janssen, Novartis and MSD.

D Prieto-Alhambra’s research group has received research grants from Amgen, Servier and UCB; speaker fees from Amgen and UCB; educational grants from Johnson & Johnson and consultancy fees from Amgen and UCB.

J-Y Reginster has received advisory board or consulting fees from IBSA-Genévrier, Pierre Fabre, Radius Health, TEVA and Mylan; lecture fees from Agnovos, IBSA-Genévrier, Mylan, CNIEL, Dairy Research Council (DRC) and Theramex and institutional grant support from IBSA-Genévrier, Mylan, CNIEL and Radius Health.

R Rizzoli has received consulting fees or advisory board fees from Radius Health, Labatec, Danone, Nestlé, CNIEL and Sandoz.

K Saag reports grant support from Amgen and Radius and consulting fees from Amgen, Radius and Roche.

Figures

Fig. 1
Fig. 1
Assessment guidelines based on the ten-year probability of a major osteoporotic fracture (%). The dotted line denotes the intervention threshold. Where assessment is made in the absence of BMD, a BMD test is recommended for individuals where the probability assessment lies in the orange region i.e. between the lower assessment threshold (LAT) and the upper assessment threshold (UAT). The intervention threshold and BMD assessment thresholds used are those derived from [1] and reproduced in the Appendix, Table 5, with kind permission from Springer Science and Business Media
Fig. 2
Fig. 2
Infographic outlining of the characterisation of fracture risk by FRAX major osteoporotic fracture probability in postmenopausal women. Initial risk assessment uses FRAX with clinical risk factors alone. FRAX probability in the red zone indicates very high risk and that an initial course of anabolic treatment followed by antiresorptive therapy may be appropriate. FRAX probability in the green zone suggests low risk, with advice to be given on lifestyle, calcium and vitamin D nutrition and menopausal hormone treatment considered. FRAX probability in the intermediate (orange) zone should be followed by BMD assessment and recalculation of FRAX probability including femoral neck BMD. After recalculation, risk may be in the red zone (very high risk), orange zone (high risk, which suggests initial antiresorptive therapy) or green zone (low risk, either in the original green zone or in the original orange zone but below the intervention threshold). Note that patients with a prior fragility fracture are at least designated at high risk and possibly at very high risk dependent on the FRAX probability
Fig. 3
Fig. 3
Treatment pathways according to the categorisation of fracture risk. For treatment modalities (inhibitors of bone resorption, anabolic agents, etc.), see Appendix, Table 6
Fig 4
Fig 4
Proportion (%) of postmenopausal women by age in a simulated normal population of 50633 women from the UK [51] characterised at low, high and very high risk. The high-risk category includes women with a prior fracture not characterised at very high risk. Numbers in the high and very high risk categories refer to the percentage so characterised at each age interval
See this image and copyright information in PMC

Comment in

References

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