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FRAX-based osteoporosis treatment guidelines for resource-poor settings in India

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Abstract

Summary

Using the FRAX® model for India, thresholds for osteoporosis evaluation and treatment without bone mineral density measurement were derived and were validated in a cohort of 300 patients. We suggest the use of this newer age and ethnic-specific FRAX®-derived thresholds for management of osteoporosis in India.

Purpose

Our study aimed to formulate population-specific intervention thresholds for treatment of osteoporosis in India which can be used even without dual X-ray absorptiometry (DXA).

Methods

Using the FRAX® model for India, thresholds for different age groups for men and women were calculated without bone mineral density (BMD) measurement. The lower assessment threshold (LAT) was based on the 10-year probability of a major osteoporosis fracture (MOF) or hip fracture (HF) equivalent to patients without clinical risk factors. The intervention threshold (IT) was based on the 10-year probability equivalent to patients with fracture. The upper assessment threshold (UAT) was set at 1.2 times the IT. Probability-based thresholds for no intervention (LAT), treatment initiation (UAT) and BMD assessment (between LAT and UAT) were derived. The thresholds were validated in a cohort of 300 patients who were referred for BMD testing.

Results

Graphs for age, gender, BMI and ethnic-specific LAT, IT and UAT for MOF and HF are derived. In the validation cohort, BMD testing to initiate/defer treatment was required in only 32.3% patients. The intervention thresholds derived without BMD testing were valid in 98.7% patients. Use of National Osteoporosis Foundation (NOF) guidelines would have resulted in overtreatment in 56/300 (18.6%) patients.

Conclusion

We suggest the use of this newer age and ethnic-specific FRAX®-derived thresholds for management of osteoporosis. Adopting these cut-offs will ensure that those requiring osteoporosis treatment will not be denied of it just because of lack of a DXA machine and will also help avoid overtreatment.

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Data availability

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Code availability

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References

  1. Cosman F, de Beur SJ, LeBoff MS, Lewiecki EM, Tanner B, Randall S, Lindsay R, National Osteoporosis Foundation (2014) Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int 25(10):2359–2381. https://doi.org/10.1007/s00198-014-2794-2

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Mithal A, Bansal B, Kyer CS, Ebeling P (2014) The Asia-Pacific regional audit—epidemiology, costs, and burden of osteoporosis in India 2013: a report of international osteoporosis foundation. Indian J Endocrinol Metab 18(4):449–454. https://doi.org/10.4103/2230-8210.137485

    Article  PubMed  PubMed Central  Google Scholar 

  3. Melamed A, Vittinghoff E, Sriram U, Schwartz AV, Kanaya AM (2010) BMD reference standards among South Asians in the United States. J Clin Densitom 13(4):379–384. https://doi.org/10.1016/j.jocd.2010.05.007

    Article  PubMed  PubMed Central  Google Scholar 

  4. Population based reference standards of peak bone mineral density of Indian males and females: An ICMR multi-center task force study′ 2010, New Delhi: ICMR Publication; Published by Director General, p. 1-24.

  5. Kanis JA, Harvey NC, Cooper C, Johansson H, Odén A, McCloskey EV (2016) A systematic review of intervention thresholds based on FRAX. Arch Osteoporos 11(1):25

    Article  PubMed  PubMed Central  Google Scholar 

  6. Tosteson AN, Melton L, Dawson-Hughes B, Baim S, Favus MJ, Khosla S et al (2008) Cost-effective osteoporosis treatment thresholds: the United States perspective. Osteoporos Int 19(4):437–447. https://doi.org/10.1007/s00198-007-0550-6

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. McCloskey E, Kanis JA, Johansson H, Harvey N, Oden A, Cooper A et al (2015) FRAX-based assessment and intervention thresholds—an exploration of thresholds in women aged 50 years and older in the UK. Osteoporos Int 26(8):2091–2099. https://doi.org/10.1007/s00198-015-3176-0

    Article  CAS  PubMed  Google Scholar 

  8. Kanis JA, McCloskey EV, Johansson H, Strom O, Borgstrom F, Oden A (2008) the National Osteoporosis Guideline Group. Case finding for the management of osteoporosis with FRAX®—assessment and intervention thresholds for the UK. Osteoporos Int 19:1395–1408 Erratum 2009. Osteoporos Int 20: 499–502

    Article  CAS  PubMed  Google Scholar 

  9. Johansson H, Azizieh F, al Ali N, Alessa T, Harvey NC, McCloskey E, Kanis JA (2017) FRAX-vs. T-score-based intervention thresholds for osteoporosis. Osteoporos Int 28(11):3099–3105. https://doi.org/10.1007/s00198-017-4160-7

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Khashayar P, Keshtkar A, Ostovar A, Larijani B, Johansson H, Harvey NC, Lorentzon M, McCloskey E, Kanis JA (2019 Nov) FRAX-based intervention and assessment thresholds for osteoporosis in Iran. Osteoporos Int 30(11):2225–2230

    Article  CAS  PubMed  Google Scholar 

  11. World Health Organization (WHO). Guide to Physical Measurements (Step 2). WHO STEPS Surveillance. 2008.

  12. Asirvatham AR, Balachandran K, Kannan S, Balasubramaniam SK, Mahadevan S (2018) FRAX first–pragmatic approach in resource poor settings. Indian J Endocrinol Metab 22(6):757–759. https://doi.org/10.4103/ijem.IJEM_412_18

    Article  PubMed  PubMed Central  Google Scholar 

  13. Leslie WD, Majumdar SR, Lix LM, Johansson H, Oden A, McCloskey E et al (2012) High fracture probability with FRAX® usually indicates densitometric osteoporosis: implications for clinical practice. Osteoporos Int 23(1):391–397. https://doi.org/10.1007/s00198-011-1592-3

    Article  CAS  PubMed  Google Scholar 

  14. Gadam R, Schlauch K, Izuora K (2013) FRAX prediction without BMD for assessment of osteoporotic fracture risk. Endocr Pract 19(5):780–784. https://doi.org/10.4158/EP12416.OR

    Article  PubMed  PubMed Central  Google Scholar 

  15. Sharma P, Nagar MM, Shukla J, Dingra M, Badoni N, Gupta P (2017) FRAX prediction with and without BMD for assessment of osteoporotic fracture risk in the Himalayan state of India: a comparative study. Int J Orthop Sci 3:114–117. https://doi.org/10.22271/ortho.2017.v3.i4b.19

    Article  Google Scholar 

  16. Thomsen K, Ryg J, Matzen L, Hermann AP, Masud T (2014) Choice of osteoporosis guideline has important implications for the treatment decision in elderly women referred to a fall clinic. Dan Med J 61:A4980

    PubMed  Google Scholar 

  17. Kyriakos G, Vidal-Casariego A, Fernández-Martínez MN, Blanco-Suárez MD, Ballesteros-Pomar MD, Cano-Rodríguez I (2015) Impact of the NOGG and NOF guidelines on the indication of bone mineral density in routine clinical practice. J Clin Densitom 18(4):533–538. https://doi.org/10.1016/j.jocd.2015.08.001

    Article  PubMed  Google Scholar 

  18. Bolland MJ, Grey A (2010) Disparate outcomes from applying UK and US osteoporosis treatment guidelines. J Clin Endocrinol Metab 95(4):1856–1860. https://doi.org/10.1210/jc.2009-2157

    Article  CAS  PubMed  Google Scholar 

  19. Bansal B, Mithal A, Chopra SR, Bhanot S, Kuchay MS, Farooqui KJ (2018) Judicious use of DXA-BMD in assessing fracture risk by using clinical risk factors in the Indian population. Arch Osteoporos 13(1):115

    Article  PubMed  Google Scholar 

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Author notes

  1. Lakshmi Nagendra

    Present address: Department of Endocrinology, K.S. Hegde Medical Academy, P.O. Nityanandanagar, Mangalore, Karnataka, 575018, India

Authors and Affiliations

  1. Department of Endocrinology, Amrita Institute of Medical Sciences, Cochin, Kerala, India

    Nisha Bhavani, V. Usha Menon, Praveen V. Pavithran, Arun S. Menon, Nithya Abraham, Vasantha Nair & Harish Kumar

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  1. Lakshmi Nagendra
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  2. Nisha Bhavani
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  3. V. Usha Menon
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Contributions

Concepts: LN, NB, UMV, NA, HK; design: LN, NB, VN; definition of intellectual content: LN, NB, NA, HK; literature search: LN, NB, PVP, VN; clinical studies: LN, NB, UMV, PVP, AM, HK; data acquisition: LN, NB, UMV, PVP, AM; data analysis: LN, NB, PVP; statistical analysis: LN, NB; manuscript preparation: LN, NB, UMV, PVP, AM; manuscript editing: LN, NB, UMV, NA, VN, HK; manuscript review: LN, NB, UMV, PVP, AM, NA, VN, HK; guarantor: LN, NB, UMV

Corresponding author

Correspondence to Lakshmi Nagendra.

Ethics declarations

Ethics approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Conflict of interest

None

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Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The research work was done when Lakshmi Nagendra was doing Senior Residency at the Department of Endocrinology, Amrita Institute of Medical Sciences, Cochin, Kerala, India.

Supplementary Information

Supplementary Fig. 1

Flowchart representing categorisation of the study cohort into 4 groups based on the application of intervention thresholds and the validation of risk categorisation after BMD measurement (PNG 56 kb)

Supplementary Fig. 2

Receiver operating characteristic (ROC) curve to study the ability of FRAX-MOF and FRAX-HF to predict fragility fractures. Area under the curve (AUC) for FRAX-MOF is 0.819 and for FRAX-HF is 0.757 (PNG 66 kb)

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Nagendra, L., Bhavani, N., Menon, V.U. et al. FRAX-based osteoporosis treatment guidelines for resource-poor settings in India. Arch Osteoporos 16, 69 (2021). https://doi.org/10.1007/s11657-021-00931-8

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