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Osteoporosis
In the Fracture Prevention trial, ambulatory women with osteoporosis
Figure 1: Relationship Between Fracture Risk Variables
who had been post-menopausal for at least five years were
randomised to receive daily self-administered, subcutaneous injections 70 70
A B
of placebo, teriparatide 20mcg or teriparatide 40mcg plus daily
60
Women with and without
60
Women with prevalent
prevalent vertebral fracture(s) vertebral fracture(s)
calcium (1,000mg) and vitamin D (400–1,200IU) supplementation. In
50
(entire cohort)
50
the MORE trial, ambulatory women who had been post-menopausal
40 40
30 30
for at least two years were randomised to receive daily oral placebo,
Women
20 20 without
raloxifene 60mg or raloxifene 120mg plus daily calcium supplements
prevalent
Absolute fracture risk (%)
10
Absolute fracture risk (%)
10 vertebral
of 500mg and 400–00IU of vitamin D. The median observation period
fracture(s)
0 0
was 21 months in the Fracture Prevention trial and 23 months using
0-1-2-3-4-5-6 0-1-2-3-4-5-6
two-year MORE trial data. Fracture severity was assessed using the
Femoral neck T-score Femoral neck T-score
visual semi-quantitative vertebral deformity scoring system of
Genant,
23
using lateral thoracic and lumbar spine radiographs
70 70
C SQ score D
Number of prevalent
obtained at baseline and study end-point of the Fracture Prevention 60 60
vertebral fractures
3
≥3
trial and at two years in the MORE trial. The SDI for a subject was
50 50
2 2
defined as the sum of the individual vertebral deformity scores. In both
40 40
1
30 30
trials, dual-energy X-ray absorptiometry (DXA) BMD was assessed at
1
20 20
the lumbar spine, femoral neck and total hip. A logistic regression
0
0
Absolute fracture risk (%) 10
Absolute fracture risk (%)
10
model was used to relate the risk of a new fracture (vertebral, fragility
0 0
non-vertebral and any fracture) at two years (yes/no) to baseline
0-1-2-3-4-5-6 0-1-2-3-4-5-6
prevalent vertebral fracture status, baseline femoral neck BMD, years
Femoral neck T-score Femoral neck T-score
post-menopausal and age.
SDI Score
70
The results from these analyses indicate that, across a range of BMD
The relationship between femoral neck
E
60
7
T-score and the 23-month any fracture
values, women without vertebral fractures had a relatively low two-
6
risk without consideration of prevalent
50 5
vertebral fracture status (A);
year risk of future fracture, while those with vertebral fractures had an
4
40 considering presence versus absence
3
increased risk. The risk of future fracture increased with greater 30
of prevalent vertebral fracture(s) (B);
2
number and severity of prevalent vertebral fractures and with
20
1
considering maximum semi-
quantitative (SQ) prevalent vertebral
increasing SDI.
Absolute fracture risk (%) 10
0
deformity score (C); considering
number of prevalent vertebral
0
fractures (D); and considering prevalent
spine deformity index (SDI) score (E).
Figure 1A illustrates the expected inverse relationship between 0-1-2-3-4-5-6
femoral neck T-score and two-year risk for any fracture for the overall
Femoral neck T-score
cohort, and in Figure 1B the relationship between these variables is
shown for patients according to prevalent vertebral fracture status.
Reprinted with the permission of Osteoporosis International.
Prevalent vertebral fractures were associated with a greater risk of
future fracture than the overall group, whereas no prevalent vertebral Conclusion
fracture was associated with a lower risk of future fracture than the Based on these findings, risk assessments using only BMD may
overall group. overestimate the true risk of future fractures in patients without
vertebral fractures and underestimate the true risk of future fractures
Figures 1C to 1E illustrate the relationship between femoral neck in patients with vertebral fractures. Data such as these can assist
T-score and any fracture risk for patients with varying vertebral clinicians in estimating the probability of future fractures. By
fractures status. At all BMD values, increasing maximum severity co-ordinating the baseline BMD T-score with the line representing the
(see Figure 1C), number of vertebral fractures (see Figure 1D) and appropriate prevalent vertebral fracture status, the absolute risk of a
spinal deformity score (see Figure 1E) were associated with greater fracture over approximately two years can be estimated. Considering
future fracture risk. Across a range of BMD values, prevalent vertebral the numerous pharmacological and non-pharmacological options
fracture burden as assessed by SDI was associated with an increased available to clinicians to treat patients with varying levels of future
risk of future vertebral fractures by up to 12-fold and non-vertebral fracture risk, clinical decision-making may be facilitated by considering
fractures by about two-fold, and any fractures by up to seven-fold (see both BMD and prevalent vertebral fracture burden in assessing short-
Figure 1E). term fracture risk in post-menopausal women. ■
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96 EUROPEAN MUSCULOSKELETAL REVIEW 2007
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