1. Cost Effective Treatment of Osteoporosis Utilizing the US Adapted WHO Fracture Risk Algorithm Sanford Baim MD, FACR, CCD Colorado Center for Bone Research Lakewood, Colorado

3. WHO Bone Density Criteria: A Diagnostic Threshold Diagnostic criteria* Classification T is above or equal to -1 Normal T is between -1 and -2.5 Osteopenia (low bone mass) T -2.5 or lower Osteoporosis T -2.5 or lower + fragility fracture Severe established osteoporosis * T-score is the number of standard deviations above or below the average peak bone density in young adults

4. Treatment Guidelines Prior to 2008 Based on BMD and CRFs T-score thresholds Treat Do not Treat BMD + CRFs NOF NOF Risk Factors AACE Risk Factors NAMS Risk Factors ACOG Risk Factors ALL Fragility Fracture (with or without low BMD) -2.5 -2.0 -1.5

7. BMD and Relative Risk Bone Density (T-score) Relative Risk for Fracture Marshall, BMJ, 1996

8. Gradients of Risk in Women for a 1 SD Decrease in BMD Below Age-adjusted mean Site of Measurement Distal radius Hip Lumbar spine Forearm Fracture 1.7 1.4 1.5 Hip Fracture 1.8 2.6 1.6 Vertebral Fracture 1.7 1.8 2.3 All Fractures 1.4 1.6 1.5 Marshall, BMJ, 1996

12. Problem with Fracture Prediction Using T-scores and WHO Diagnostic Criteria

13. C Number of subjects BMD in Patients With and Without Fractures EPOS Study Group, JBMR , 2002

15. Effect of Gradient of Risk on Prediction of Future Fracture Risk

16. Age as an Independent Risk Factor for Fracture Adapted from Kanis , OI , 2001 Probability of clinical osteoporotic fractures in Swedish women Gradient of risk Ten Year Fracture Probability (%) Age 80 70 60 50

17. Prior Fracture as an Independent Risk Factor for Fracture Klotzbuecher , JBMR , 2000 RR Incident Fracture Prevalent Fracture Wrist Vertebra Hip Wrist 3.3 1.7 1.9 Vertebra 1.4 4.4 2.3 Hip NA 2.5 2.3

18. Combined Effect of BMD and Clinical Risk Factors on Fracture Risk Rate of hip fracture (per 1000 woman-yr) Calcaneal bone density No. of risk factors Cummings, N EJM, 1995 27.3 14.7 9.4 0 5 10 15 20 25 30 Lowest third Middle third Highest third 0-2 3-4 >4

19. Fracture Probability

28. FRAX Beta-Site http://www.shef.ac.uk/FRAX/tool

29. FRAX Beta-Site http://www.shef.ac.uk/FRAX/tool

30. FRAX – USA (Caucasian Female) http://www.shef.ac.uk/FRAX/tool

31. FRAX USA – (Hispanic female) http://www.shef.ac.uk/FRAX/tool

32. FRAX USA – (Asian female) http://www.shef.ac.uk/FRAX/tool

33. FRAX – USA (Black female) http://www.shef.ac.uk/FRAX/tool

34. Secondary osteoporosis / No BMD Secondary osteoporosis + BMD Secondary osteoporosis/No BMD+RA BMD without secondary CRFs ☻ ☻ ☻ ☻

35. Low BMI / No BMD Normal BMI / No BMD Normal BMI + BMD Low BMI + BMD

39. FRAX Patch http://www.orost.com/fraxpatch

43. Summary Courtesy of Mike McClung www.orost.com/fraxpatch

44. Courtesy of Mike McClung www.orost.com/fraxpatch

49. NOF Clinician’s Guide To Prevention and Treatment of Osteoporosis Development Committee Bess Dawson-Hughes (Chair), NOF Robert Lindsay (Co-chair), NOF Sundeep Khosla, NOF L. Joseph Melton III, NOF Anna N.A. Tosteson, NOF Murray Favus, ASBMR Sanford Baim, ISCD Interspecialty Medical Council Reviewers Laura Tosi, AAOS Kenneth W. Lysles, AGS Martin Grabois, AAP Helena W. Rodbard, AMA Richard W. Kruse, AAP Marc F. Swiontkowski, AOA Partricia Graham, AAPMR Kendrin Van Steenwyk, AOA Donald Berman, AACE Shonni Silverberg, ASBMR William C. Andrews, ACOG E. Michael Lewiecki, ISCD Michael Gloth III, ACP John L. Melvin, ISPRM Ronald Bernard Staron, ACR Wendi El-Amin, NMA Lenore Buckley, ACRheum Carolyn Becker, TES

59. Impact of Duration in Fracture-Loss in Quality of Life on 10-year Hip Fracture Which Treatment Becomes Cost-effective Tosteson, OI , 2008

62. 10-year Fracture Risk 50 Year Old White Female with BMI 24 5.2% 0.4% 9.4% 2.5% 2.5% 9.2% 16% 2.6% 10% 4.3% 17% 4.5% 28% 8.3%

63. 2003 NOF Physician Guide Treatment Recommendations Core data from Kanis, OI , 2001 McClung, Bone , 2005

64. 2008 NOF Clinician Guide Treatment Recommendations Core data from Kanis , OI, 2001 McClung, Bone, 2005 NOF Clinician Guide, 2008, www.NOF.org