Web Site Can Help Determine Whether You Need Medication to Prevent Fractures

By Olivier Uyttebrouck Journal Staff Writer

Louise Cox-Walker doesn’t want to take medications to prevent bone loss, and a new online tool helped convince her doctor that she doesn’t need them.

"I’ll do whatever I have to do not to take drugs," said Cox- Walker, who is in her 60s and fears side effects of osteoporosis medications, which can include irritation of the stomach or esophagus.

Her physician, Dr. E. Michael Lewiecki, recently used a new online tool called FRAX to assist his diagnosis. He decided that Cox- Walker doesn’t need medications, at least not for now.

FRAX, a fracture risk assessment tool released this year by the World Health Organization, uses an online questionnaire to calculate a person’s risk of fracturing a bone within 10 years. The National Osteoporosis Foundation also published a set of guidelines to help physicians interpret the results.

The tool is intended to help doctors move beyond an almost complete dependence on bone mineral density testing when they diagnose patients, he said.

"In the past, we’ve been a little too reliant on bone density to determine who needs to be treated," said Lewiecki, director of the New Mexico Clinical Research and Osteoporosis Center in Albuquerque. "The health of your bones is determined by more than just your bone density."

For example, age is a key risk factor for fracture. But previous guidelines issued by the National Osteoporosis Foundation did not consider the age of a postmenopausal woman, Lewiecki said.

Bone density testing, which uses mild X-rays, remains central to the FRAX calculation. The patient’s bone mineral density score, or T- score, is one of 12 factors the calculator uses to derive a 10-year probability of fracture.

But the FRAX tool also considers age, sex, ethnicity, weight, height, and a variety of medical and lifestyle factors, including tobacco and alcohol use.

Though FRAX remains in the testing phase, Lewiecki said he believes the tool is useful for people like Cox-Walker who have osteopenia, a condition where bone density is lower than normal.

Osteopenia presents a doctor with a dilemma, he said. The condition may be a precursor to more serious osteoporosis, but not necessarily.

Cox-Walker, who is one of an estimated 34 million Americans with osteopenia, may never develop osteoporosis or suffer a broken bone, Lewiecki said. So, does she need medications or not?

"She’s the perfect situation for FRAX to help us out," he said. "I was a little bit uncertain about whether to recommend treatment and FRAX helped me make a decision."

FRAX estimates that Cox-Walker has an 18 percent chance of experiencing a fracture within 10 years.

The National Osteoporosis Foundation guidelines recommend that patients with a fracture risk of 20 percent or greater should be treated, Lewiecki said. Treatment typically involves medications in the bisphosphonate family, such as Fosamax, which are intended to slow bone loss.

Lewiecki said he wants to re-evaluate Cox-Walker in about a year. If she shows a higher probability of fracture or if she breaks a bone, the physician may recommend medications, he said.

"As you get older, your probability of breaking a bone gets greater, even if your bone density stays the same," he said. Understanding the risk

FRAX is an online tool that calculates a person’s risk of bone fracture within 10 years. It was introduced in February by the World Health Organization to help doctors diagnose bone disease and recommend an appropriate treatment. Anyone can view and use the calculator at www.shef.ac.uk/FRAX and link to "calculation tool."

The National Osteoporosis Foundation provides a wealth of information about the disease on its Web site at www.nof. org. Here are some basic facts and tips:

Osteoporosis is a disease in which bones become fragile and more likely to break. If not prevented or if left untreated, osteoporosis can progress painlessly until a bone breaks. These broken bones, also known as fractures, occur typically in the hip, spine and wrist.

An estimated 10 million Americans have osteoporosis. An additional 34 million have low bone mass, or osteopenia, placing them at increased risk for osteoporosis. Experts recommend five steps that can improve bone health and help prevent osteoporosis. They are:

Get the daily recommended amounts of calcium and vitamin D.

Engage in regular weight-bearing and muscle-strengthening exercise.

Avoid smoking and excessive alcohol.

Talk to your health care provider about bone health.

Have a bone density test and take medication when appropriate.

Certain factors that increase the likelihood of developing osteoporosis. They include:

Being female.

Older age.

Family history of osteoporosis or broken bones.

Being small and thin.

People of certain ethnicities are at particular risk, including Anglos, Asians, and Hispanics.

History of broken bones.

Low estrogen levels in women, including menopause.

Missing periods (amenorrhea).

Low levels of testosterone and estrogen in men.

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