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Targeted bone density testing for optimizing fracture prevention in Canada

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Abstract

Summary

The Canadian FRAX® tool used without bone mineral density (BMD) is highly sensitive for identifying individuals qualifying for pharmacotherapy based upon an intervention threshold of 20% for major osteoporotic fracture risk (MOF) computed with BMD.

Introduction

This analysis was performed to inform initial BMD testing as part of Osteoporosis Canada’s Guidelines Update for women and men at average risk, assuming a pharmacotherapy intervention threshold of 20% for FRAX® MOF computed with BMD.

Methods

Women and men age 50 + without previous low-trauma fracture or high-risk medication use were identified in a BMD registry for the province of Manitoba, Canada. Fracture probability assessments with the Canadian FRAX® tool were computed without and with BMD (denoted MOF-clinical and MOF-BMD, respectively).

Results

The study population consisted of 50,700 women (mean age 65.5 ± 9.4 years) and 4152 men (69.2 ± 10.0 years). FRAX MOF-clinical score was > 10% in 33.8% of women and 13.3% of men (P < 0.001). The median (interquartile range [IQR]) age for MOF-clinical to reach 10% in women was 70 (69–72) and 65 years (62–67) years in the absence and presence of additional FRAX clinical risk factors, respectively. In men, comparable ages were 83 years [82–86] and 76 [70–78] years. Using MOF-BMD of 20% as the intervention threshold, 4.3% of women and 0.7% of men qualified for treatment. MOF-clinical > 10% had high sensitivity to identify those qualifying for treatment (99.3% in women and 99.1% in men). An age-based rule (“BMD testing is indicated at age 70 if no additional FRAX clinical risk factors are present, or at age 65 if one or more clinical risk factors exists”) gave similarly high sensitivity (women 99.9% and men > 99.9%).

Conclusions

FRAX without BMD offers an effective strategy to identify individuals meeting the current Canadian treatment threshold based upon FRAX® with BMD (≥ 20%). Moreover, this can be operationalized using simple age cutoffs of 70 years in the absence of additional clinical risk factors and 65 years in the presence of additional clinical risk factors.

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Acknowledgments

The authors thank the Osteoporosis Canada Guidelines Update Fracture Risk Assessment Working Group for guidance as this work evolved. The authors acknowledge the Manitoba Centre for Health Policy for use of data contained in the Population Health Research Data Repository (HIPC 2016/2017-29). The results and conclusions are those of the authors and no official endorsement by the Manitoba Centre for Health Policy, Manitoba Health, Seniors and Active Living, or other data providers is intended or should be inferred. This article has been reviewed and approved by the members of the Manitoba Bone Density Program Committee. SNM is chercheur-boursier des Fonds de Recherche du Québec en Santé. LML is supported by a Tier I Canada Research Chair.

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Correspondence to W.D. Leslie.

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William Leslie and Lisa Lix has no conflicts of interest. Suzanne Morin has nothing to declare for the context of this paper but has received research grants, Amgen. Neil Binkley has nothing to declare for the context of this paper but has received research support (paid to institution) from Radius and GE Healthcare and consultant/advisory board fees from Amgen.

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Leslie, W., Morin, S., Lix, L. et al. Targeted bone density testing for optimizing fracture prevention in Canada. Osteoporos Int 31, 1291–1297 (2020). https://doi.org/10.1007/s00198-020-05335-x

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