Crystal ball gazing, the fine art in modern science: OSTEOPOROSIS
As medicine moves from fixing problems to preventing them, like from fixing fractures to preventing Osteoporosis, the clinician has to finesse the art of predicting who is most at risk, so as to channel finite resources to such, and also to limit possible side-effects which are inherent to any treatment.
In Osteoporosis, there are 3 key questions:
1) Who to screen (with BMD)?
2) Who to treat?...
3) Who to pause treatment (drug holiday)?
I did not consider "Treat with what?" as a major conundrum (as is in RA) because the agents currently available have fairly similar efficacy-risk-cost (generics not considered) considerations, with numbers-needed-to-treat/harm (NNT/NNH) balanced out.
This 2014 NOF guidelines help to answer 1) & 2). 3) with regards to bisphosphonates was tackled in yesterday's post.
Every region and country has formulated its own set of guidelines on Osteoporosis screening and treatment that best serves their particular population's risk profile, taking into account the available resources for undertaking such programmes nationally.
In answer to the question "Who to treat?", most if not all agree that FRAX is now adequately refined and nuanced in accounting for most fracture risk factors, and well contextualised and validated in the various population g...roups.
What is not universally agreed is the 10-year probability of hip or major fracture thresholds: what percentage is too high and should therefore deserve treatment? In reimbursement markets, this is an arbitrary number for health economists to decide. In a self-paying market, it's a consultative and relational art between the doctor and the patient, much like that between a financial advisor and the client.
These are Singapore's Osteoporosis clinical practice guidelines. The useful recommendation is the simple tool, OSTA, to answer the question "Who to screen?"
They were issued in 2009, so FRAX was not mature then. It's time to update the SG guidelines.
FRAX has 2 major shortcomings, as I see it.
Firstly, it's unwieldy. You need either an online computer or a paid app to key in a list of data. Then you get 2 percentages. Then the patient asks what the numbers mean. If your answer went something like, "you have a 10-year probability of hip fracture of x% and a major non-hip fracture of y%", your computer or smartphone had just taken over your job. You see the disconnect. It reminds me of the trilogy (in 4 parts), "The Hitchh...iker's Guide to the Galaxy" (betraying my vintage): when the question, "What is the answer to life, the universe and everything?" was asked of the supercomputer Deep Thought, and the answer came out as "42".
But I digress. The bigger problem is that FRAX does not take falls propensity into consideration. Many fragility fractures do not occur if patients do not fall (so there is no pressing need to treat a bedbound frail elderly). This shortcoming was admitted by the FRAX group in their 2011 position statement.