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BMD loss not a risk factor for major osteoporotic fractures
Leslie WD. J Clin Endocrinol Metab. 2012;doi:10.1210/jc.2011-2871.
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Loss of bone mineral density detected during routine clinical monitoring did not appear to be a significant independent risk factor for major osteoporotic fractures, according to researchers for the Manitoba Bone Density Program.
The researchers performed a retrospective cohort study using a database that included all clinical BMD results for Manitoba, Canada. The study included 4,498 untreated women who were aged 40 years and older at the time of a second BMD test performed between April 1996 and March 2009. Proximal femur and lumbar spine DXA scans were performed.
The researchers identified 146 women with major osteoporotic fractures after the second BMD test. The annualized percentage change in total hip BMD was no greater in women with fractures compared with women without fractures. After adjustment for final total hip BMD, other covariates and medication use, rate of total hip BMD change did not predict major osteoporotic fractures. This was similar for analyses of change in lumbar spine and femoral neck BMD.
“We found no evidence that BMD loss as detected during routine clinical monitoring was able to enhance prediction of major osteoporotic fractures over the final BMD measurement alone,” the researchers wrote. “This would suggest that algorithms for estimating fracture risk can rely upon a recent static BMD measurement and do not need to consider BMD loss as an additional variable.”
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The paper serves an important purpose in that it does provide a warning that using rate of bone loss as an independent risk factor for predicting fracture risk does not seem to have merit. Since some people have incorporated the concept of rate of loss into their algorithms for fracture risk, this paper has a useful function. However, if you look at the T-scores of the patients in the study, they are unusually high. Most fracture risk reduction studies specifically select patients who already have fractures or have very low T-Scores, typically less than –2.5, which is the definition of osteoporosis. If you have a population of patients where the fracture risk is low to begin with, then any technique you use to assess fracture risk is going to be compromised. Although this study is interesting, I think clinicians would say that they’re not looking at rate of bone loss to predict fracture risk, but rather to prevent the patient from getting below a certain threshold where her risk of fracture is going to increase. We should not use rate of bone loss as an independent predictor of fracture risk, but we should acknowledge the fact that if the patient is losing bone rapidly, she should be treated.
– Donald A. Bergman, MD
Endocrine
Today Editorial Board member
Disclosure: Dr. Bergman reports no relevant financial disclosures.
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