frax is a computer-based algorithm which
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FRAX is a computer-based algorithm which uses easily obtained clinical risk factorsto estimate an individual’s 10-year fracture probability.It may be utilized by clinicians to assist in the identification of patients at high risk forfractures.
INTRODUCTORY STATEMENT
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The FRAX model determines the predictive importance of each clinical risk factor, as well as interactions between them, to optimize the accuracy of fracture probability.
It is primarily used as a clinical tool to help physicians assess fracture probability.
FRAX aid in identifying which individuals may be candidates for bone density evaluation or pharmacological treatment.
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FRAX does not take into account all risk variables ( ex. falls, markers of bone turnover levels, other bone density assessments, as well as certain secondary causes of osteoporosis).
FRAX uses yes/no answers and the average risk is computed.
Does not take into account the variation of risks associated with high or low doses of glucocorticoids, the number and type of prior fractures, or the quantity of alcohol or tobacco consumption.
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2010 ISCD-IOF FRAX Initiative and ISCD Position Development Conference
Bucharest, RomaniaNovember 12-14, 2010
Sanford Baim, MDAssociate Professor of Medicine
Division of EndocrinologyUniversity of Miami, Miller School of
Medicine
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FRAX may underestimate fracture probability in individuals with a parental history of non-hip fragility fracture.
Bone turnover markers are not included as risk factors in FRAX.
FRAX CLINICAL STATEMENTS
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Impaired functional status in patients with rheumatoid arthritis may be a risk factor for clinical fractures.
FRAX may underestimate fracture probability in such patients.
There is no consistent evidence that non-glucocorticoid medications for rheumatoid arthritisalter fracture risk.
FRAX CLINICAL STATEMENTSA.R.
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Paciente mujer 45 años con diagnostico de Artritis Reumatoide de 1 año de evolución con afectación de manos.
Sinovitis persistente de 3 meses de evolucionTratamiento.
Prednisolona 2.5 mg dia desde hace 9 meses. Metotrexate 7.5 mg semanal Ac folico . 1 mg dia
Naproxeno 250 mg dia
Rx manos. Erpsion marginal
VSG, 25FR. PositivoAnticitrulina . Neg
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Artritis Reumatoide de la manoDedos Fusiformes
© ACR
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AR mostrando hinchazón persistente a nivel de las AR mostrando hinchazón persistente a nivel de las articulaciones IFPs junto con afectación de las MCFs articulaciones IFPs junto con afectación de las MCFs
que son dolorosas a la exploración clínicaque son dolorosas a la exploración clínicaColección de diapositivas ACR
Prednisolona 10 mg dia
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Paciente 45 años con diagnostico de Artritis Reumatoide de 5 años de evolución con afectación de manos, hombros, rodillas.
Sinovitis persistente con formación de pannus sinovial.Limitación a la movilidad de hombros.Desviación cubital en manos
Tratamiento.Prednisolona dosis variables 5-15 mg día desde hace 18
meses. Coticoides IM de forma indisciplinada mtx 15 mg semanal
Embrel 50 mg semanal.ac folico
Rx manos. Erosiones óseas . Subluxacion.
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Artritis Reumatoide de la manoMala alineación
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58 year old women. 8 years beyond menopause. Weight 60.5 Kg. No personal or family history of fracture.
BMD FN T-score = -2.4
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77 year old women. Weight 53.6 Kg.. Mother experienced a hip fracture.
BMD: FN T-score = -1.4
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There is a relationship between number of prior fractures and subsequent fracture risk. FRAX underestimates fracture probability in persons with a history of multiple fractures.
There is a relationship between severity of prior vertebral fractures and subsequent fracture risk. FRAX may underestimate fracture probability in individuals with prevalent severe vertebral fractures.
FRAX CLINICAL STATEMENTS
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L1(G2)
L1(G3)
L4(G3)
L2(G1)
L2(G2)
L5(G2)
L5(G3)
L2(G2)
L1(G2)
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There is a dose relationship between glucocorticoid use of greater than 3 months and fracture risk. The average dose exposure captured within FRAX is likely to be a prednisone dose of 2.5- 7.5 mg/day or its equivalent. Fracture probability is under-estimated when prednisone dose is greater than 7.5 mg/day and is over-estimated when prednisone dose is less than 2.5 mg/day.
Frequent intermittent use of higher doses of glucocorticoidsincreases fracture risk. Because of variability in the dose and dosing schedule, quantification of this risk is not possible.
High dose inhaled glucocorticoids may be a risk factor for fracture. FRAX may underestimate fracture probability in users of high dose inhaled glucocorticoids.
FRAX CLINICAL STATEMENTS
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Paciente varon 53 años, con antecedentes de (LES) lupus eritematoso sistemico en tratamiento a largo plazo con dosis altas de prednisona
› T-score columna Lumbar -1.6› T-score Cuello femoral -1.0 ( 2005)› T-score cuello femoral -1.6 ( 2007)
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Edad 51 a. / 2005
Steroid & Multi fractures
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Steroid & Multi fractures
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Steroid & Multi fractures
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Inicial 1-23-02 Estudio Actual 11-08-12Steroid & Multi fractures
T12
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Existe correlacion entre el uso de corticoides por mas de 3 meses y el riesgo de fractura
El promedio de dosis de corticoides incorporado en el FRAX es de 2.5 a 7.5 mg dia de prednisona o su equivalente
la probabilidad de fractura es subestimada cuando la dosis de prednisona es mayor de 7.5 mg/dia, y es sobre estimada cuando la
dosis de prednisona es menor de 2.5 mg/dia
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Debilidad sobre la dicotomía del uso del esteroide› FRAX asume un promedio de dosis expuesta
de esteroides (equivalente a la dosis media de GPRD)› > 7.5 mg de prednisona dia , indica mayor
riesgo de fractura que el que predice el FRAX.
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Debilidad sobre la dicotomia del uso del esteroide› FRAX asume un promedio de dosis de
esteroides› > 7.5 mg de prednisona dia , indica mayor
riesgo de fractura que el que predice el FRAX.
L a Obesidad podria no ser protectorala masa muscular puede no incrementarse con el peso
“Cuando QUEREMOS INTERPRETAR POSIBILIDADES, E
S
NECESARIO UTILIZAR EL JUICIO CLINICO”
“Cuando QUEREMOS INTERPRETAR POSIBILIDADES, E
S
NECESARIO UTILIZAR EL JUICIO CLINICO”
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While there is evidence that duration and dose of tobacco smoking may impact on fracture risk, quantification of this risk is not possible.
Falls are a risk factor for fractures but are not accommodated as an entry variable in the current FRAX model. Fracture probability may be underestimated in individuals with a history offrequent falls, but quantification of this risk is notcurrently possible.
FRAX CLINICAL STATEMENTSCigarrillo/caidas
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Varon 76 a. con antecedentes de múltiples caídas, hipertensión, hiperlipidemia, osteoartritis de rodilla y cadera, nicturia.› 25(oh) D = 26 ng/ml› Atorvastatina› ASA› HCTZ› metoprolol› Alprazolan› multivitamina
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Caidas multiples
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• Las caídas son un factor de riesgo para fracturas, pero no están incorporada como variable en el actual modelo de FRAX. La probabilidad de fractura podría estar subestimada en individuos con historia de caídas frecuentes, pero la cuantificación de este riesgo actualmente no es posible
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Riesgo de fractura parece ser mas elevado que el calculado por FRAX
Necesita realzmente los medicamentos para OSP?› Probablemnte reduciendo los
medicamentos, evaluando la parte nutricional ( BMI de 20 Kg/m2), considerar terapia fisica para fortalecimiento en MMII, evaluar por asistencia para soporte y estabilidad.
Pensar sobre el paciente y no solo
sobre la DMO o el calculo FRAX
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Measurements other than BMD or T-score at the femoral neck by Dual-energy X-ray Absorptiometry (DXA) are not recommended for use inFRAX.
FRAX may underestimate or overestimate major osteoporotic fracture risk when lumbar spine T-score is much lower or higher (>1 Standard Deviation discrepancy) than femoral neck T-score
FRAX BMD STATEMENTS
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• mujer 66 años• Fumadora• Menopausia 51 a.• Antecedentes de familiar de fractura• HTA . En tto. Con amlodipino
– Cuello femoral t-score -1.7– CL t-score – 3.5
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Discordancia CL / femur
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Discordancia CL / femur
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Frax riesgo mayor 12 %
Acorde con las guías canadienses la paciente esta justo por debajo del corte del 20%
Pero…… CL t-score -3.5
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Measurements other than BMD or T-score at the femoral neck by Dual-energy X-ray Absorptiometry (DXA) are not recommended for use in FRAX.
FRAX may underestimate or overestimate major osteoporotic fracture risk when lumbar spine T-score is much lower or higher (>1 Standard Deviation discrepancy) than femoral neck T-score
FRAX BMD STATEMENTS
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Algunas medidas con excepción de la DMO o T score a nivel del cuello femoral, no es recomendado para el uso del frax
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Cuello femoral› Predice todas las
fracturas +++› Predice fractura de
cadera +++› NHANES +++› Artefactos/exclusion
+› Mayoria de
cohortes en derivacion*
Columna lumbar› Predice todas las
fracturas +++› Predice fractura de
cadera ++› No equivalente› Artefactos/
exclusion +++› Minoria en
derivacion de cohorte**
*38,973 medidas en cuello de femur ( Johnell: JBMR 2005 20,1185-1194**19,071 se realizaron ambas mediidas ( Kanis OI 2005 17 527-534
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FRAX subestima o sobreestima el riesgo mayor de fractura osteoporotica cuando el t-score de columna lumbar es mas alto o bajo (≥ 1 discrepancia DS) que el t-score de cuello femoral.