Osteoporosis treatment: The X factors - FRAX and DEXA

Care of the patient with osteoporosis can begin in the inpatientsetting, where pharmacists have an important role in treatmentand prevention of fractures. There are things that the outpatientpharmacist can do as well, according to Mary Beth O'Connell,PharmD, BCPS, FASHP, FCCP, associate professor, Eugene ApplebaumCollege of Pharmacy and Health Sciences, Wayne State University,Detroit.

Dr. O'Connell outlined the latest National OsteoporosisFoundation (NOF) standards and the FRAX standards (which estimatefracture risk over the next 10 years) and how they need to beadjusted for data from the United States. She also gave attendeesinformation on how they can interpret data on vitamin Dconcentrations, as well as DEXA results.

"Prior to the use of the World Health Organization's FRAX tool[see full information at www.shef.ac.uk/FRAX/], we knew that 1 in 5 women have hip fractures and 1 in 15 menwill have hip fractures," says Dr. O'Connell. "In 2005, therewere 2 million hip fractures [in the United States] and most ofthose were preventable. After a fracture, an individual has agreater likelihood of getting another fracture.

"Osteoporosis is definitely a public health concern," she adds."But most of our seniors are not getting adequate education onfracture prevention [even though its incidence is higher whencompared] to MI or stroke. There are approximately four times asmany osteoporosis-related fractures [in this population] than MIsor stroke, but prevention is not mainstream for ourseniors."

New guidelines, prevention toolsDr. O'Connell explains that there are new guidelines from NOF (www.nof.org) where pharmacists canregister as healthcare providers and get free information andreference tools. Internationally, the WHO criteria are being usedand have been updated with the new FRAX tool.

The FRAX web site is a new calculation tool that covers ninecountries. "You ask the patient a series of questions, and yourresults will predict the likelihood of hip fracture within thenext 10 years," she explains. One caveat: "When using this toolin the United States, you have to convert the T score from DEXAto the T score in the FRAX because the results from the UnitedStates will [reflect] older NHANES data."

Independent risk factors in the FRAX scoring include age, lowBMI, history of fragility fracture (although Dr. O'Connell notesthat this tool only looks at mother's or father's history of hipfracture), smoking status, use of glucocorticoids, and rheumatoidarthritis. Secondary causes include diabetes type 1,long-standing untreated hyperthyroidism, hypogonadism orpremature menopause (<45 years of age), chronic malnutrition,malabsorption, or liver disease. Another risk factor is excessalcohol use (increases falls at >3 units/day).