A new position paper from the International Osteoporosis Foundation (IOF) and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) addresses the rationale for separate diagnostic and intervention thresholds in the osteoporosis.
In ‘The need to distinguish intervention thresholds and diagnostic thresholds in the management of osteoporosis‘, the authors explain why the diagnostic criteria established by the WHO for osteoporosis have been useful in this field and recommend that they be maintained, while a distinction should be made between diagnostic and intervention thresholds. They point to the successful distinction between diagnostic and intervention thresholds in the cardiovascular field.
Professor John Kanis, lead author and IOF Honorary President, states:
“The huge treatment gap in the management of patients at increased risk of fractures, even in patients who have already had a fracture, is a major problem. The reasons for this are many, including a lack of awareness among doctors and patients themselves. However, it has been suggested that the flaw lies in the diagnostic definition of osteoporosis as defined by the WHO in 1994. This has led some to argue that a change in diagnostic criteria would improve the low rate of treatment in patients with high risk. .”
“While the intention is laudable, we find a change in definition problematic and there is little evidence that this alone would improve management.”
The WHO diagnostic definition of osteoporosis is a bone mineral density (BMD) that is 2.5 standard deviations (SD) or more below the mean value for healthy young women, that is, a T-score ≤-2.5 OF. The definition provided a standardized description that allowed comparison of the prevalence of osteoporosis between countries and regions, and secular trends. The definition of osteoporosis rapidly gained general acceptance, demonstrated by its almost immediate use in clinical practice and research, and by its adoption as an inclusion criterion for drug trials.
Despite these advantages, it is now clear that BMD alone is a poor screening tool and is not ideal as a threshold for intervention. Most people who sustain a fragility fracture do not have BMD in the range of osteoporosis. This is comparable to the relationship between hypertension and stroke, where high blood pressure is a major cause of stroke, but most people with stroke are not hypertensive. Furthermore, a given T-score threshold has a different meaning at different ages and countries.
With this new awareness, the field of osteoporosis has moved towards fracture risk assessment, with or without BMD, to establish intervention thresholds. The position paper describes the increasing use of prior fracture and FRAX probability (the most widely used fracture risk assessment tool) as the intervention threshold.
Professor Jean-Yves Reginster, co-author and president of ESCEO, stated:
“The use of intervention thresholds based on the probability of fracture is increasingly implemented in routine clinical practice, but this does not minimize the value of current diagnostic criteria that allow us to quantify the burden of disease. The BMD-based operational definition, unique in the musculoskeletal field, is in complete agreement with clinical expectations of disorder burden. It is analogous to that successfully employed for the use of continuously distributed clinical risk variables in the management and prevention of other multifactorial outcomes such as myocardial infarction (by defining hypercholesterolemia) and stroke (by defining hypertension). It has produced a regulatory framework in the US, the EU and elsewhere that has enabled the development of a wide range of therapeutic interventions.”
Professor Kanis concluded:
“The BMD-based operational definition is a triumph in health care, and there is no intellectually sound reason to advocate change at this time. We recommend retaining the BMD-based definition of osteoporosis while bringing greater clarity to the distinction between diagnostic and intervention thresholds, as has been successfully managed in cardiovascular disease.”
Kanis JA, McCloskey EV, Harvey NC, Cooper C, Rizzoli R, Dawson-Hughes B, Maggi S, Reginster JY. The need to distinguish intervention thresholds and diagnostic thresholds in the management of osteoporosis. Osteoporos Int (2022). https://doi.org/10.1007/s00198-022-06567-9
About the IOF
The International Osteoporosis Foundation (IOF) is the world’s largest non-governmental organization dedicated to the prevention, diagnosis and treatment of osteoporosis and related musculoskeletal diseases. IOF members, including committees of scientific researchers and more than 300 patient, medical and research organizations, work together to make fracture prevention and healthy mobility a global priority in health care. https://www.osteoporosis.foundation @iofbonehealth
The need to distinguish intervention thresholds and diagnostic thresholds in the management of osteoporosis
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