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Osteoporotic fractures, early prevention will get twice the result with half the effort! The 23rd Asia-Pacific Rheumatism Alliance (APLAR) Online Conference was successfully held in Kyoto, Japan on August 28~31, 2021.
Professor Sumapa Chaiamnua from Phramongkutklao Medical Center in Thailand brought you the "Guideline Update on Osteoporosis" 》Special report
.
Be vigilant! The most serious consequence of OP is fracture osteoporosis (OP) is the most common systemic bone disease characterized by low bone mass and damage to the microstructure of bone tissue, leading to increased bone fragility and prone to fractures
.
OP is divided into two categories, primary and secondary, and can occur at any age
.
Primary OP includes postmenopausal OP (type Ⅰ), senile OP (type Ⅱ) and idiopathic OP (including adolescent type): postmenopausal OP generally occurs within 5 to 10 years after menopause in women; senile OP generally refers to OP occurs after 70 years of age; idiopathic OP mainly occurs in adolescents, and the cause is unknown
.
Secondary OP refers to OP caused by any diseases and/or drugs that affect bone metabolism and other clear causes
.
The most serious consequence of OP is fragility fractures, which can cause pain and severe disability.
Among them, hip and vertebral fractures can reduce life expectancy.
The fatality rate within 1 year of long-term bedridden patients can reach 20%, and the permanent disability rate can reach 50%.
.
Therefore, it is very important to strengthen the understanding of OP fractures
.
Professor Chaiamnua introduced to everyone the relationship between the International Osteoporosis Foundation (IOF)/European Osteoporosis and Osteoarthritis Clinical Economics (ESCEO) 2020 Guidelines and the American Association of Clinical Endocrinologists (AACE) 2020 Guidelines Updates Content
.
The OP guidelines update is closely related to the rapid development of diagnosis and treatment technology and drugs
.
More and more evidence supports that different sequential treatment options should be adopted for patients with different fracture risks, and emerging bio-targeted drugs are gradually entering the clinic
.
AACE has more detailed diagnostic criteria for OP.
Fractures caused by OP are becoming more and more common in women after 55 years of age and men after 65 years of age, which can lead to a large number of bone-related diseases, and increase mortality and medical expenses
.
The World Health Organization (WHO) first defined OP in 1994, using T-score to classify osteopenia (Osteopenia, -2.
5＜T value＜-1.
0) and osteoporosis (Osteoporosis, T value≤-2.
5)
.
2020 AACE provides more detailed insights on the diagnostic criteria for postmenopausal OP and fractures, as shown in the figure below
.
Figure 1 The 2020 AACE diagnostic criteria for postmenopausal osteoporosis first uses FRAX to assess the risk of fracture, and then uses the BMD assessment classification IOF/ESCEO 2020 version of the guidelines to detail the low, high and very high risk OP fracture algorithm Explained and pointed out the importance of bone mineral density (BMD) in OP in postmenopausal OP in assessing fracture risk and clinical intervention nodes
.
In clinical practice, BMD measured by dual-energy X-ray bone densitometer (DXA) is usually closely related to fracture risk
.
For every 1 SD reduction, the overall risk of fracture increases by 1.
5 to 2 times.
Therefore, most risk assessment paradigms include BMD
.
However, BMD also has limitations, that is, most fractures occur in individuals whose BMD T score does not meet the conventional definition of OP (-2.
5 or lower), so the sensitivity is low when used alone for OP screening
.
Fortunately, many clinical risk factors that are easily identifiable and independent of BMD (such as age, gender, and previous fracture history) are associated with fracture risk and can be used to assess fracture risk with or without BMD
.
Several fracture risk assessment tools have been developed to estimate absolute fracture risk based on these clinical factors
.
Fracture Risk Assessment Tool (FRAX) is the most widely studied software tool and has been included in clinical practice guidelines
.
It differs from other tools in that it can be calibrated directly based on the incidence of fractures in the target population.
FRAX can estimate the occurrence of severe OP fractures (a combination of hip, spine, forearm, and proximal humerus fractures) in 10 years.
Probability or only the probability of a hip fracture
.
The fracture risk algorithm/process that combines clinical risk factors and BMD is now widely used in clinical practice.
It is proposed in the IOF/ESCEO 2020 updated guidelines that FRAX should be used to conduct the earliest fracture risk assessment for OP patients.
People at risk also need to undergo BMD to determine their risk classification
.
Professor Chaiamnua pointed out that patients with high risk factors for fractures should be evaluated by the FRAX model first, such as long-term use of corticosteroids, type 2 diabetes, chronic kidney disease, fracture history within 2 years, those with high risk of BMD and T score, and history of trauma and so on
.
Figure 2 Guidelines for evaluating the probability (%) of major osteoporotic fractures based on a 10-year Note: The dotted line indicates the intervention threshold
.
If the assessment is performed without BMD, it is recommended to perform BMD testing on individuals whose probability assessment is located in the orange area, that is, between the lower assessment limit (LAT) and the upper assessment limit (UAT)
.
Figure 3 Treatment approach according to fracture risk classification Professor Chaiamnua proposed the new concept of imminent fracture risk, which is a new measure to strengthen fracture risk assessment in routine clinical practice
.
Studies have shown that the risk of fracture after OP is time-dependent, and the risk of fracture in the first 2 years is much higher than at other times
.
Identifying individuals who are at high risk of fractures within 1 to 2 years may help to choose more potent, faster onset, but more expensive drugs
.
Fig.
4 Adjacent fracture risk Different fracture risk, different treatment options have discovered the key ways to regulate bone resorption and formation, and identify new treatment methods with unique mechanisms of action
.
OP is a chronic disease that requires long-term (sometimes lifelong) management
.
The guidelines point out that for all postmenopausal women, life>
.
In addition, it is necessary to evaluate the risk of fracture within 10 years in conjunction with the country's OP prevention and treatment guidelines
.
Individuals with a higher risk of fracture can receive treatment with bisphosphonates or desulumab for up to 10 years
.
For people with very high fracture risk or emergency risk, treatment with teriparatide or abalotide should be considered
.
However, because the treatment time of these drugs is limited to 18 to 24 months, anti-resorption drugs should continue to be used for treatment
.
The AACE guidelines elaborate on personalized diagnosis and treatment plans for extremely high fracture risks and high fracture risks
.
The AACE guidelines recommend that all patients with secondary OP need to be screened.
The test items include complete blood count, serum calcium, 25 (OH) vitamin D, blood biochemistry, 24-hour urine calcium, urine sodium, urine creatinine and other indicators
.
The current situation is that people at high risk of fractures are not receiving adequate treatment, and the strategy to solve this treatment gap is an important challenge in the future
.
Summary: In the end, Professor Chaiamnua concluded that although progress has been made in fracture risk assessment and there are a series of effective options for reducing the incidence of fractures, the treatment rate for high-risk groups is not high
.
The description of the OP intervention window in the AACE guidelines will be more conducive to the clinical diagnosis and treatment process, and the initial treatment plan must be based on the results of the fracture risk assessment.
The high-risk population prefers bisphosphonates, and the extremely high-risk population prefers bio-targeted drugs.
.
Experts comment that with the aging of the population, the incidence of OP and fractures (fragility fractures) caused by OP is increasing year by year
.
Due to the disease itself (such as rheumatoid arthritis) and the medications (such as glucocorticoids) in patients with rheumatism, the incidence of OP and osteoporotic fractures is significantly higher than that of healthy people
.
The most recent guidelines include the 2020 AACE/ACE Osteoporosis Guidelines, which focus on fracture risk assessment, and have important updates and highlights in the diagnosis of OP, the selection of anti-osteoporosis drugs, and the course of treatment
.
Focus on fracture risk assessment, emphasizing the use of the WHO Fracture Risk Assessment Tool (FRAX) or other fracture risk assessment tools for clinical fracture risk assessment during the initial assessment
.
Broaden the diagnostic criteria and add low bone mass/low bone mass (T value -2.
5 to -1.
0), but the corresponding national FRAX assessment suggests an increased risk of fracture, as a new diagnostic criterion for osteoporosis
.
In terms of treatment, medical treatment is proposed to be "stratified", that is, to stratify patients with osteoporosis based on high-risk and extremely high fracture risk, and based on this, to choose the initial medicine and course of treatment, emphasizing the existence of extremely high fracture risk Patients should take more aggressive treatment
.
In terms of anti-osteoporosis drugs, in addition to teriparatide, abalotide, and disulfumab, a new drug with a two-way mechanism of action has been added to romozumab (romosozumab), which can bind to sclerostatin and inhibit both Bone resorption also promotes bone formation, and it is recommended for the rescue treatment of patients with extremely high fracture risk
.
The new guidelines and advances in diagnosis and treatment will enable more patients with reduced bone strength and increased fracture risk to be diagnosed with osteoporosis, so as to have the opportunity to receive individualized treatment and management to reduce the occurrence of fractures
.
However, studies have shown that the current diagnosis and treatment rate of high-risk groups of osteoporotic fractures is not high, and the diagnosis and treatment of osteoporosis is a long way to go! Expert profile Associate Professor Gao Jie Director of the Department of Rheumatology and Immunology, Doctor of Medicine, Associate Chief Physician, and Associate Professor of Shanghai Changhai Hospital Youth Committee Member of Shanghai Medical Association Rheumatology Branch Member of Shanghai Medical Association Osteoporosis Branch Copyright statement The original text of this article is welcome to forward to the circle of friends-End-The medical community strives to be accurate and reliable when the content is reviewed, but it is not about the timeliness of the published content, and the accuracy and completeness of the cited information (if any), etc.
Make any promises and guarantees, and assume no responsibility for the outdated content and the possible inaccuracy or incompleteness of the cited information
.
Relevant parties are requested to check separately when adopting or using this as a basis for decision-making
.
Osteoporotic fractures, early prevention will get twice the result with half the effort! The 23rd Asia-Pacific Rheumatism Alliance (APLAR) Online Conference was successfully held in Kyoto, Japan on August 28~31, 2021.
Professor Sumapa Chaiamnua from Phramongkutklao Medical Center in Thailand brought you the "Guideline Update on Osteoporosis" 》Special report
.
Be vigilant! The most serious consequence of OP is fracture osteoporosis (OP) is the most common systemic bone disease characterized by low bone mass and damage to the microstructure of bone tissue, leading to increased bone fragility and prone to fractures
.
OP is divided into two categories, primary and secondary, and can occur at any age
.
Primary OP includes postmenopausal OP (type Ⅰ), senile OP (type Ⅱ) and idiopathic OP (including adolescent type): postmenopausal OP generally occurs within 5 to 10 years after menopause in women; senile OP generally refers to OP occurs after 70 years of age; idiopathic OP mainly occurs in adolescents, and the cause is unknown
.
Secondary OP refers to OP caused by any diseases and/or drugs that affect bone metabolism and other clear causes
.
The most serious consequence of OP is fragility fractures, which can cause pain and severe disability.
Among them, hip and vertebral fractures can reduce life expectancy.
The fatality rate within 1 year of long-term bedridden patients can reach 20%, and the permanent disability rate can reach 50%.
.
Therefore, it is very important to strengthen the understanding of OP fractures
.
Professor Chaiamnua introduced to everyone the relationship between the International Osteoporosis Foundation (IOF)/European Osteoporosis and Osteoarthritis Clinical Economics (ESCEO) 2020 Guidelines and the American Association of Clinical Endocrinologists (AACE) 2020 Guidelines Updates Content
.
The OP guidelines update is closely related to the rapid development of diagnosis and treatment technology and drugs
.
More and more evidence supports that different sequential treatment options should be adopted for patients with different fracture risks, and emerging bio-targeted drugs are gradually entering the clinic
.
AACE has more detailed diagnostic criteria for OP.
Fractures caused by OP are becoming more and more common in women after 55 years of age and men after 65 years of age, which can lead to a large number of bone-related diseases, and increase mortality and medical expenses
.
The World Health Organization (WHO) first defined OP in 1994, using T-score to classify osteopenia (Osteopenia, -2.
5＜T value＜-1.
0) and osteoporosis (Osteoporosis, T value≤-2.
5)
.
2020 AACE provides more detailed insights on the diagnostic criteria for postmenopausal OP and fractures, as shown in the figure below
.
Figure 1 The 2020 AACE diagnostic criteria for postmenopausal osteoporosis first uses FRAX to assess the risk of fracture, and then uses the BMD assessment classification IOF/ESCEO 2020 version of the guidelines to detail the low, high and very high risk OP fracture algorithm Explained and pointed out the importance of bone mineral density (BMD) in OP in postmenopausal OP in assessing fracture risk and clinical intervention nodes
.
In clinical practice, BMD measured by dual-energy X-ray bone densitometer (DXA) is usually closely related to fracture risk
.
For every 1 SD reduction, the overall risk of fracture increases by 1.
5 to 2 times.
Therefore, most risk assessment paradigms include BMD
.
However, BMD also has limitations, that is, most fractures occur in individuals whose BMD T score does not meet the conventional definition of OP (-2.
5 or lower), so the sensitivity is low when used alone for OP screening
.
Fortunately, many clinical risk factors that are easily identifiable and independent of BMD (such as age, gender, and previous fracture history) are associated with fracture risk and can be used to assess fracture risk with or without BMD
.
Several fracture risk assessment tools have been developed to estimate absolute fracture risk based on these clinical factors
.
Fracture Risk Assessment Tool (FRAX) is the most widely studied software tool and has been included in clinical practice guidelines
.
It differs from other tools in that it can be calibrated directly based on the incidence of fractures in the target population.
FRAX can estimate the occurrence of severe OP fractures (a combination of hip, spine, forearm, and proximal humerus fractures) in 10 years.
Probability or only the probability of a hip fracture
.
The fracture risk algorithm/process that combines clinical risk factors and BMD is now widely used in clinical practice.
It is proposed in the IOF/ESCEO 2020 updated guidelines that FRAX should be used to conduct the earliest fracture risk assessment for OP patients.
People at risk also need to undergo BMD to determine their risk classification
.
Professor Chaiamnua pointed out that patients with high risk factors for fractures should be evaluated by the FRAX model first, such as long-term use of corticosteroids, type 2 diabetes, chronic kidney disease, fracture history within 2 years, those with high risk of BMD and T score, and history of trauma and so on
.
Figure 2 Guidelines for evaluating the probability (%) of major osteoporotic fractures based on a 10-year Note: The dotted line indicates the intervention threshold
.
If the assessment is performed without BMD, it is recommended to perform BMD testing on individuals whose probability assessment is located in the orange area, that is, between the lower assessment limit (LAT) and the upper assessment limit (UAT)
.
Figure 3 Treatment approach according to fracture risk classification Professor Chaiamnua proposed the new concept of imminent fracture risk, which is a new measure to strengthen fracture risk assessment in routine clinical practice
.
Studies have shown that the risk of fracture after OP is time-dependent, and the risk of fracture in the first 2 years is much higher than at other times
.
Identifying individuals who are at high risk of fractures within 1 to 2 years may help to choose more potent, faster onset, but more expensive drugs
.
Fig.
4 Adjacent fracture risk Different fracture risk, different treatment options have discovered the key ways to regulate bone resorption and formation, and identify new treatment methods with unique mechanisms of action
.
OP is a chronic disease that requires long-term (sometimes lifelong) management
.
The guidelines point out that for all postmenopausal women, life>
.
In addition, it is necessary to evaluate the risk of fracture within 10 years in conjunction with the country's OP prevention and treatment guidelines
.
Individuals with a higher risk of fracture can receive treatment with bisphosphonates or desulumab for up to 10 years
.
For people with very high fracture risk or emergency risk, treatment with teriparatide or abalotide should be considered
.
However, because the treatment time of these drugs is limited to 18 to 24 months, anti-resorption drugs should continue to be used for treatment
.
The AACE guidelines elaborate on personalized diagnosis and treatment plans for extremely high fracture risks and high fracture risks
.
The AACE guidelines recommend that all patients with secondary OP need to be screened.
The test items include complete blood count, serum calcium, 25 (OH) vitamin D, blood biochemistry, 24-hour urine calcium, urine sodium, urine creatinine and other indicators
.
The current situation is that people at high risk of fractures are not receiving adequate treatment, and the strategy to solve this treatment gap is an important challenge in the future
.
Summary: In the end, Professor Chaiamnua concluded that although progress has been made in fracture risk assessment and there are a series of effective options for reducing the incidence of fractures, the treatment rate for high-risk groups is not high
.
The description of the OP intervention window in the AACE guidelines will be more conducive to the clinical diagnosis and treatment process, and the initial treatment plan must be based on the results of the fracture risk assessment.
The high-risk population prefers bisphosphonates, and the extremely high-risk population prefers bio-targeted drugs.
.
Experts comment that with the aging of the population, the incidence of OP and fractures (fragility fractures) caused by OP is increasing year by year
.
Due to the disease itself (such as rheumatoid arthritis) and the medications (such as glucocorticoids) in patients with rheumatism, the incidence of OP and osteoporotic fractures is significantly higher than that of healthy people
.
The most recent guidelines include the 2020 AACE/ACE Osteoporosis Guidelines, which focus on fracture risk assessment, and have important updates and highlights in the diagnosis of OP, the selection of anti-osteoporosis drugs, and the course of treatment
.
Focus on fracture risk assessment, emphasizing the use of the WHO Fracture Risk Assessment Tool (FRAX) or other fracture risk assessment tools for clinical fracture risk assessment during the initial assessment
.
Broaden the diagnostic criteria and add low bone mass/low bone mass (T value -2.
5 to -1.
0), but the corresponding national FRAX assessment suggests an increased risk of fracture, as a new diagnostic criterion for osteoporosis
.
In terms of treatment, medical treatment is proposed to be "stratified", that is, to stratify patients with osteoporosis based on high-risk and extremely high fracture risk, and based on this, to choose the initial medicine and course of treatment, emphasizing the existence of extremely high fracture risk Patients should take more aggressive treatment
.
In terms of anti-osteoporosis drugs, in addition to teriparatide, abalotide, and disulfumab, a new drug with a two-way mechanism of action has been added to romozumab (romosozumab), which can bind to sclerostatin and inhibit both Bone resorption also promotes bone formation, and it is recommended for the rescue treatment of patients with extremely high fracture risk
.
The new guidelines and advances in diagnosis and treatment will enable more patients with reduced bone strength and increased fracture risk to be diagnosed with osteoporosis, so as to have the opportunity to receive individualized treatment and management to reduce the occurrence of fractures
.
However, studies have shown that the current diagnosis and treatment rate of high-risk groups of osteoporotic fractures is not high, and the diagnosis and treatment of osteoporosis is a long way to go! Expert profile Associate Professor Gao Jie Director of the Department of Rheumatology and Immunology, Doctor of Medicine, Associate Chief Physician, and Associate Professor of Shanghai Changhai Hospital Youth Committee Member of Shanghai Medical Association Rheumatology Branch Member of Shanghai Medical Association Osteoporosis Branch Copyright statement The original text of this article is welcome to forward to the circle of friends-End-The medical community strives to be accurate and reliable when the content is reviewed, but it is not about the timeliness of the published content, and the accuracy and completeness of the cited information (if any), etc.
Make any promises and guarantees, and assume no responsibility for the outdated content and the possible inaccuracy or incompleteness of the cited information
.
Relevant parties are requested to check separately when adopting or using this as a basis for decision-making
.
