Treatment indications and thresholds of intervention: consensus and controversies in osteoporosis

Abstract

A few indications for treatment and thresholds for intervention in osteoporosis have been propounded in the literature and recommended in guidelines. These include a bone mineral density (BMD) T-score ≤ −2.5, fracture probability-based scores and the presence of a fragility fracture. A low BMD is associated with an increased risk of fracture. However, a BMD T-score of ≤ −2.5 on its own does not capture fracture risk in its entirety. Fracture risk assessment tools that are based on clinical risk factors arose from the misgivings about using BMD T-scores in isolation to assess fracture risk. Algorithms such as FRAX, Garvan etc, integrate various clinical risk factors with or without BMD to compute the probability of a hip fracture or a major osteoporotic fracture over a finite period. These probabilities do not yield distinctive thresholds by themselves and need to be interpreted wisely and adopted by consensus. Evidence exists to show that treatment can decrease the risk of sustaining a second fracture. Therefore, patients with a fragility fracture should be considered for treatment. In this narrative interview, we will explore the strengths and limitations of some of these indications for treatment and will discuss the various points of contention surrounding them.

治疗指征和干预阈值：骨质疏松症的共识和争议 摘要

已有文献提出骨质疏松症的治疗指征及干预阈值, 并在指南中推荐。其中包括骨密度（BMD）T评分≤-2.5, 骨折风险评分和是否存在脆性骨折。BMD减低会增加骨折风险。然而, BMD T评分≤-2.5本身并不能完全反映骨折风险。基于单独使用BMD T评分评估骨折风险的疑虑, 可对具有临床风险因素的患者采用骨折风险评价工具。FRAX骨折风险评价工具、Garvan评估法等整合了各种临床风险因素, 可联合或不联合BMD, 计算在一定时间内发生髋关节骨折或重大骨质疏松性骨折的可能性。这些可能性本身并没有限定明确的阈值, 因此需要谨慎解释, 达成共识后再采用。已有证据表明, 治疗可以降低再次骨折的风险。因此, 脆性骨折患者应考虑治疗。本文将探讨这些治疗指征的优势和局限性, 并讨论与之相关的各种争议。

Keywords:

• Intervention thresholds
• indications
• treatment
• osteoporosis
• fragility fractures
• FRAX
• T-score
• controversies
• consensus

Potential conflict of interest

M. Chandran has received honoraria for lectures from Amgen and DKSH, and has served on advisory board meetings of Amgen and UCB. A. Kwee does not have any conflicts of interest to disclose.

Source of funding

Nil.