Osteoporosis Criteria Expanded to Include Fracture Risk

March 6, 2014

An expert working group says osteoporosis can be diagnosed in postmenopausal women and older men with only marginally low bone density, if they have fractured certain bones in a minor mishap, show vertebral fractures on X-ray, or have high fracture risk for other reasons.

Siris ES, Adler R, Bilezekian J et al, The clinical diagnosis of osteoporosis: a position statement from the National Bone Health Alliance Working Group. Osteoporosis International. (Epub ahead of print). DOI DOI 10.1007/s00198-014-2655-z

An expert working group under the National Bone Health Alliance has broadened the formal diagnostic definition for osteoporosis beyond the single criterion of a bone mineral density (BMD) T-score of -2.5 or less. It now recommends that postmenopausal women and men aged 50 years or older should be diagnosed with osteoporosis if they have a demonstrably elevated risk for future fractures.

This is the same population as that included in the National Osteoporosis Foundation Clinician's Guide to the Prevention and Treatment of Osteoporosis.

Individuals in these categories who sustain a fracture of a vertebra, proximal humerus, or the pelvis in a low-energy mishap should also be considered to have osteoporosis if they have osteopenia, as defined by a T-score between -1.0 and -2.5, according to the new definition.

This recommendation is the outcome of deliberations by a working group of 17 clinicians and scientists formed in 2012 by the National Bone Health Alliance, based on concern that the T-score-only criterion regularly overlooks treatable osteoporosis that portends a high risk of future fractures.

Too often when older patients sustain a fracture after a stumble, they wrote in the new report, the fracture is blamed on the fall without considering the fragility of the bones. "It is our hope," they added, "that these new criteria will compel a more thoughtful assessment of overall fracture risk."

The working group concurred that:

•  Osteoporosis can be diagnosed with or without a BMD test in someone who experiences a low-trauma fracture of the hip (e.g., from a standing fall).

• The incidental finding of a vertebral fracture on an X-ray may be diagnostic of osteoporosis if, in the clinician's best judgment, it was the result of reduced bone mass and bone strength.

•  In some cases a low-trauma wrist or forearm fracture may also be diagnostic, depending on the circumstances (probably not for a 50-year-old woman with minimally low BMD who fell while rollerblading, but likely for a 64-year-old with a T-score of -2.2 who tripped on a curb).

•  Osteoporosis can also be diagnosed if, by the criteria of the World Health Organization-sponsored FRAX tool, the 10-year probability of hip fracture is 3% or greater or that of major osteoporotic fracture is above 20%. (Corticosteroid-induced osteoporosis is one of the risk factors contemplated in the FRAX assessment.)

The working group report points out that many clinical trials of osteoporosis treatments have defined the condition based only on T-scores rather than on fracture history or FRAX. It advises clinicians contemplating treatment for a particular patient with osteoporosis defined by the new criteria to consider whether there is existing evidence of effectiveness for that treatment, absent a T-score diagnosis.