Risk Assessment First Urged for Fragility Fracture Screening

A brand new Canadian guideline on screening for the first prevention of fragility fractures recommends threat evaluation first, earlier than bone mineral density (BMD) testing, for ladies aged 65 and older. For youthful men and women aged 40 and older, screening isn’t advisable.

To develop the rule, a writing group from Canadian Activity Pressure on Preventive Well being Care commissioned systematic opinions of research on the advantages and harms of fragility fracture screenings; the predictive accuracy of present risk-assessment instruments; affected person acceptability; and advantages of remedy. Remedy harms had been analyzed by way of a speedy overview of opinions.

The rule, revealed on-line Could 8 within the Canadian Medical Affiliation Journal, is geared toward major care practitioners for his or her community-dwelling sufferers aged 40 and older. The suggestions don’t apply to folks already taking preventive medicine.

Dr Roland Grad

Nondrug therapies had been past the scope of the present guideline, however pointers on the prevention of falls and different methods are deliberate, Roland Grad, MD, a suggestion writer and affiliate professor at McGill College in Montreal, instructed Medscape Medical Information.

The brand new guideline says that girls aged 65 and older could possibly keep away from fracture by screening and preventive treatment. A person’s fracture threat could be estimated with a brand new Fragility Fractures Determination Help, which makes use of the Canadian FRAX risk-assessment device.

“A threat evaluation–first strategy promotes shared decision-making with the affected person, based mostly on greatest medical proof,” Grad mentioned.

“To assist clinicians, we now have created an infographic with visuals to speak the time spent on BMD vs threat evaluation first.”

New Proof

“At the least three issues motivated this new guideline,” Grad mentioned. “After we began work on this previous to the pandemic, we noticed a necessity for up to date steerage on screening to stop fragility fractures. We had been additionally conscious of recent proof from the publication of screening trials in females older than 65.”

To conduct the danger evaluation in older ladies, clinicians are suggested to do the next:

  • Use the choice help (which sufferers may use on their very own).

  • Use the 10-year absolute threat of main osteoporotic fracture to facilitate shared decision-making about doable advantages and harms of preventive pharmacotherapy.

  • If pharmacotherapy is being thought of, request a BMD utilizing DXA of the femoral neck, then reestimate the fracture threat by including the BMD T-score into the FRAX.

Potential harms related to varied therapies, with various ranges of proof, embrace the next: with alendronate and denosumab, nonserious gastrointestinal adversarial occasions; with denosumab, rash, eczema, and infections; with zoledronic acid, nonserious occasions, comparable to headache and flulike signs; and with alendronate and bisphosphonates, uncommon however severe harms of atypical femoral fracture and osteonecrosis of the jaw.

“These suggestions emphasize the significance of excellent medical follow, the place clinicians are alert to adjustments in bodily well being and affected person well-being,” the authors write. “Clinicians also needs to pay attention to the significance of secondary prevention (ie, after fracture) and handle sufferers accordingly.”

“This is a crucial matter,” Grad mentioned. “Fragility fractures are consequential for people and for our publicly funded healthcare system. We anticipate questions from clinicians in regards to the time wanted to display screen with the danger evaluation–first technique. Our modeling work suggests time financial savings with [this] technique in comparison with a technique of BMD testing first. Following our suggestions could result in a discount in BMD testing.”

To advertise the rule, the CMAJ has recorded a podcast and can use different methods to extend consciousness, Grad mentioned. “The Canadian Activity Pressure has a communications technique that features outreach to major care, stakeholder webinars, social media, partnerships, and different techniques. The Faculty of Household Physicians of Canada has endorsed the rule and can assist promote to its members.”

Different At-Danger Teams?

Aliya Khan, MD, FRCPC, FACP, FACE, a professor within the Divisions of Endocrinology and Metabolism and Geriatrics and director of the fellowship in metabolic bone illnesses at McMaster College in Hamilton, Ontario, instructed Medscape she agrees with the technique of evaluating ladies aged 65 and older for fracture threat.

Dr Aliya Khan

“The choice help is beneficial, however I wish to see it expanded to different circumstances and conditions,” she mentioned.

For instance, Khan wish to see suggestions for younger ladies and for males of all ages relating to secondary causes of osteoporosis or drugs recognized to have a detrimental impact on bone well being. By not addressing these sufferers, she mentioned, “we could miss sufferers who would profit from a fracture threat evaluation and doubtlessly remedy to stop low-trauma fractures.”

A advice for youthful postmenopausal ladies was included in the newest Society of Obstetricians and Gynaecologists Canada guideline, she famous.

General, she mentioned, “I imagine these suggestions will cut back the surplus or inappropriate use of BMD testing and that’s welcome.”

Funding for the Canadian Activity Pressure on Preventive Well being Care is supplied by the Public Well being Company of Canada. The duty pressure members report no related monetary relationships.

CMAJ. Revealed on-line Could 8, 2023. Full textual content

Observe Marilynn Larkin on Twitter: @MarilynnL.

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