Abstract
The risk of further fractures increases 2–10 times after the first fracture. Actual fracture risk for the given person (absolute fracture risk) can be calculated from data collected in 10-year prospective studies (NHANES or Kanis 2001). To calculate absolute fracture risk one has to multiply age-related risk factor ascertained in above studies by the coefficient estimated for particular factors influencing possible fracture (relative fracture risk). The most commonly used factors are: age (RR 2.0 for each 5 yrs over 65), low BMD (RR/SD 1.4–2.6), low-energy fracture after the age of 40 (RR 4.0), proximal femur fracture in mother (*RR 1.9), body mass lower than 58 kg (*RR 1.9), early menopause – before the age of 45, smoking (RR 1.2), susceptibility to falls (*RR 3.5), corticosteroids intake.
Absolute fracture risk in 60-year-old woman whose foreseen 10-year probability of femoral neck fracture is 2.3% with normal BMD but burden by factors marked by asterisks would be: 2.3% x 1.9 x 1.9 x 3.5 = 29%. As 76% of fractures occur in women with normal BMD absolute fracture risk is the most objective information. In case of proximal femoral fracture 10-year probability of 10% or more fracture risk provides a cost effective threshold for women in Sweden.
We can increase bone mineral density by pharmacological intervention. Every patient should be given calcium and vit. D supplementation and a specific medication, which should be adjusted to: age, sex and presence of hot flashes and fractures. HRT is preferred in women aged 50–60 yrs suffering from hot flashes. HRT decreases the risk of spine (50%) and proximal femur fracture (40%). However some risk of breast and uterine cancer has to be taken into consideration. Selective estrogen modulators (SERM; raloxifene) act as estrogen agonists on bone and cardiovascular system but as antagonists on breast tissue. Decrease of spinal fracture (45%) and breast cancer incidence (70%) is proven but no positive action on proximal femur is reported.
In women who underwent osteoporotic fracture one can apply bisphosphonates, strontium ranelate or PTH. Alendronate reduces spine fractures (47%) and proximal femur fractures (51%). Similar effects are documented for risedronate (spine – 60% and proximal femur 40–56%). Strontium ranelate not only inhibits bone resorption but also stimulates bone formation. Decrease of spine and proximal femur fractures occurrence has been proven (41%). PTH injected sc. in daily doses is the most powerful compound which rebuilds bone trabeculae in severe cases and reduces incidence of peripheral fractures (53%). Calcitonin is effective in spine fractures but not in proximal femur.
Fall prevention program should be implemented in all patients with osteoporosis independently from pharmacological intervention.
Theses abstracts were prepared by Professor Roger Lemaire. Correspondence should be addressed to EFORT Central Office, Freihofstrasse 22, CH-8700 Küsnacht, Switzerland.
