Authors: Dr. Randhir Sagar Yadav, Dr. Shashi Bhushan Singh, Dr. Samir Ghimire, Dr. Raksha Sharma, Dr. Manusha Thapa Magar, Dr. Ahmed Ibrahim, Dr. Divya Koirala, and Dr. Lubna Mirza.
Affiliation: Norman Regional Health System
Osteoporosis is a condition in which the bones become porous and weak with a higher chance of fractures. Studies show that 20% of people over 50 die within a year following their hip fractures. It is essential to understand that osteoporosis is a silent disease without signs or symptoms until people fall and fracture. Therefore, screening and evaluating a high-risk individual for declining bone density is critical. Today, our Endocrinology class considered the possibility of osteoporosis in our aging parents, aunts and uncles, and grandparents.
We learned how to use the online world health organization’s fracture risk assessment tool (FRAX) accessed via www.sheffield.ac.uk/FRAX, which can be used with or without DXA bone density test results. The calculator requires information like age/date of birth, sex, height, and the patient’s weight. We must also fill in information such as history regarding the previous fracture (non-traumatic or more minor impact resulting in severe damage), fracture in parents, current smoking/alcohol intake status, use of a glucocorticoid, rheumatic arthritis, secondary osteoporosis for the risk assessment. For example, if the FRAX score is calculated as the 10-year probability of a hip fracture ≥ 3% or a 10-year chance of a major osteoporosis-related fracture ≥ 20%; in that case, it is suggested to start treatment with Vitamin D, calcium, and alendronate to reduce the risk of future fractures.
Here are a few experiences shared by a few of my students regarding calculating FRAX score and their interpretation among their family members.
Dr. Shashi Bhushan Singh, MBBS, KIST Medical College, Nepal
Someone may ask, “I feel fine. Why should I suspect I have osteoporosis with a high risk for fractures?” Let me share with you one of my experiences. I calculated the FRAX score for my grandfather with my classmates. No personal identifying information is shared, and some information is slightly altered. Neither of us had expected the results!
For example, we filled out the FRAX questionnaire on the website as follows;
- Age or Date of Birth: You can write either the age or date of birth.
Date of Birth:
- Sex: Male
- Weight (kg): 60 (You can convert pound into kg using the conversion table in the calculator)
- Height (cm): 152.4 (You can convert inch into centimeter using the conversion table in the calculator)
- Previous Fracture: No
- Parent Fractured Hip: No
- Current Smoking: No
- Glucocorticoids: No
- Rheumatoid arthritis: No
- Secondary osteoporosis: No [Enter yes if the patient has a disorder strongly associated with osteoporosis. These include type I (insulin-dependent) diabetes, osteogenesis imperfecta in adults, long-standing untreated hyperthyroidism, hypogonadism or premature menopause (<45 years), chronic malnutrition, or malabsorption and chronic liver disease]
- Alcohol 3 or more units/day: No
- Femoral neck BMD (g/cm2): Leave blank if data is not available.
The results were astonishing. I had not expected that my grandfather had such a high risk of fractures as it appeared on the surface that he had very few risk factors. After answering all the questions, my grandfather’s 10-year probability of fracture came out to be 11 (normal up to 20) for major osteoporotic fracture, whereas 5.3 ( normal up to 3) for hip fracture. Because of the increased risk of hip fracture in my grandfather, we came up with a plan to treat him with calcium, vitamin D, and anti-osteoporosis pharmacotherapy.
Now, I am happy that I screened him for osteoporosis as part of a clinical exercise in the class. I believe this finding will help my grandfather and our family greatly by reducing his risk of having debilitating fractures with a high risk for morbidity and mortality. If you have any of the risk factors for fracture mentioned above, please consider calculating your FRAX score using the online free calculator and consult your doctor for preventive therapy as indicated.
Samir Ghimire, MBBS Kathmandu Medical College, Kathmandu, Nepal
My aunt is a 59 years-old nurse who weighs approximately 48 kg with a height of 157 cm (BMI or body mass index is 19.5 kg/m2). She doesn’t have a history of tobacco smoking, alcohol consumption, glucocorticoid use, rheumatoid arthritis, or a previous fracture in herself or her parents. Additionally, some risk factors for osteoporosis in her are menopause, Asian, and nulliparity. Unfortunately, DXA bone density data is not available.
Based on her characteristics, her 10-year probability of major osteoporotic fracture and hip fracture calculated during the class today via Fracture Risk Assessment Tool (FRAX) for India is 3.4% and 0.9%, respectively, which doesn’t require drug therapy. Nonetheless, we counseled her on increasing dietary calcium intake and physical therapy.
Manusha Thapa Magar, MBBS, College Of Medical Sciences, Bharatpur, Nepal.
My grandmother is a 70-year old Asian woman who weighs 87 kg and is 152 cm tall, with a BMI of 37.7 kg/m2. She has no history of previous fracture, any use of glucocorticoids, or rheumatoid arthritis. She is a non-smoker and does not consume alcohol. However, she has diabetes and takes metformin once a day. She has a history of right leg fracture in her father in his late 70’s. With my grandmother’s permission, I calculated her FRAX score using the Fracture Risk Assessment Tool during our class, which showed a score of 11% for major osteoporotic fracture and a hip fracture score of 4.0%. Thus, she requires treatment with Vitamin D, Calcium supplements, and alendronate tablets.
Like my grandmother, osteoporosis can present as a silent disease that does not present with any symptoms. Before taking this class with Dr. Mirza, I did not know my grandmother was at high risk for osteoporotic fracture. Thankfully, with Dr. Mirza’s guidance, I was able to calculate the FRAX score and diagnose osteoporosis in my grandmother and prevent her from getting fractures in the future. We started her on vitamin D, calcium supplements, and alendronate tablets.
Dr. Ahmed Ibrahim
I calculated the FRAX score for my mom, which we learned during the class today. She is a 62 years old female, weighs 70 kg, and has a height of 152 cm. We learned that aging, female gender, smoking, alcohol use, glucocorticoid use, and rheumatoid arthritis could increase the risk for osteoporosis. In addition, there are certain other diseases such as thyroid disease, parathyroid disease, or diabetes that can also increase risk. Considering all the factors, I entered the information about my mother. Her major osteoporotic risk is ten, and hip fracture risk is 3, per the fracture risk assessment tool (FRAX). She takes oral calcium and vitamin D tablets. I learned that in addition to taking calcium and vitamin D, she should take once-weekly alendronate. We recommended it under the American association of clinical Endocrinology and Endocrine society guidelines to prevent a hip fracture. I am going to recommend this treatment to my mom. I will also encourage other elderly family members to find out their FRAX scores. It’s easy.
Dr. Raksha Sharma, MBBS, Patan Academy of Health Sciences, Lalitpur, Nepal
During one class session with Dr. Mirza, we had classwork to calculate the fracture risk using an online FRAX calculator for one of our family members with their permission. I calculated one for my grandmother since she was the oldest one in our family. She is 95 years old, and other than aging, female gender, and being post-menopausal, she has no risk factors associated with osteoporosis such as smoking, use of steroids, family history, or prior history of fractures. As 90 years being the maximum age limit for the calculation, FRAX score probability was calculated as the 10-year probability of a hip fracture ≥ 12% and the 10-year probability of a major osteoporosis-related fracture ≥ 21%. She is a very active and healthy person for her age and does not take any medications for chronic illnesses. Although she has always been receptive to advise regarding a healthy lifestyle, asking her to take medicine regularly will be challenging. We also discussed how to counsel patients about the importance of vitamin D, calcium, and alendronate. Adding its significance in improving the overall quality of life is also helpful in increasing compliance among the patient.
For my grandmother, what persuaded her to take medication was to explain how it would prevent her from getting a hunched back with vertebral fractures. Now that she has started taking vitamin D, calcium, and alendronate, we have peace of mind that my grandmother’s risk of having a hip fracture is reduced.
Randhir Sagar Yadav, MBBS, Institute of Medicine, Kathmandu, Nepal
I recall an article from BMJ (British medical journal), “Doctors do make the worst patients.” Some colleagues may rephrase this adage as “Doctors Aren’t The Worst Patients, We’re The Busiest.” While attending an endocrinology class on fracture risk, I found myself somewhere between the above two proverbs. We evaluated the fracture risk in a patient who presented to the clinic using a FRAX fracture risk calculator, and we were happy to inform him that he has a low fracture risk. Our mentor, Dr. Mirza, advised assessing the fracture risk in our family members, particularly grandparents, with their permission. While entering their approximate parameters in the online fracture risk calculator, I remembered my 75 and 77 years old grandparents, who are otherwise doing well, without any apparent risk of osteoporosis, and are in a state of good health. The smile on my face vanished when the FRAX calculator pointed them at high risk for having fragility fractures. Looking back, I am happy that we discovered that they are at increased risk for osteoporosis-related fractures. We plan to supplement them with Calcium, Vitamin D and treat them with alendronate. I was surprised that my grandparents were at risk, and no one thought about it while we treated and educated patients admitted to the hospital with fractures.
Divya Koirala, MBBS, KIST Medical College, Nepal
During one of the sessions on Osteoporosis by Dr. Mirza about calculating the fracture risk in osteoporotic bones using a FRAX calculator and implying that in our family members, I was concerned as both of my parents are aged. I calculated it for my mother, who is 67 years old, weighs 78 kg with a height of 165 cm, under glucocorticosteroids to treat osteoarthritis. I figured out her FRAX score using the given variables. It was shocking because her major osteoporotic fracture risk is 14, and her hip fracture risk is 2.3. At her age, she has been doing well, apart from her osteoarthritis. Our session enlightened me about the importance of vitamin D, calcium, and alendronate for my mother to prevent future fracture risks. I want to use this FRAX score in my community and among my patients and also the treatment protocol that we have learned from my mentor Dr. Mirza.
In layman terms, osteoporosis can be defined as thinning of bones that can lead to fragility fractures. Risk factors for osteoporosis include advanced age, female gender, low body weight, smoking, low sex hormones in menopause, and certain other diseases and medications.
FRAX score measures how likely you are to get a fracture from thinning of the bones. In addition, it will give you an idea of whether you or your loved ones need medications to prevent fragility fracture. FRAX score can be calculated by answering a series of questions mentioned on the above website.
As we learned, several of our close family members have osteoporosis based on limited provided information in this group activity. In addition, we learned that screening for osteoporosis could help us discover previously unidentified patients at high risk for fractures. The treatment of osteoporosis includes weight-bearing exercises such as walking, improving balance, taking calcium and vitamin D regularly, and taking anti-osteoporosis medications in some cases. Timely diagnosis and treatment can help prevent morbidity and mortality in these patients.