In the U.S. about 2 million men have osteoporosis.1 About 1 in 5 men will experience an osteoporotic-related fracture in his lifetime.2 In addition, men with hip fracture have a higher mortality rate compared with that of women with hip fracture.3 The National Osteoporosis Foundation guidelines and the Endocrine Society guidelines recommend that all men aged ≥ 70 years have bone mineral density (BMD) testing. Depending on risk factors, osteoporosis screening may be appropriate for men aged ≥ 50 years. A BMD with a T-score of -2.5 or lower is classified as osteoporosis.2
In addition to osteoporosis, osteopenia also negatively impacts men. Osteopenia is defined as a BMD with a T-score of -1 to -2.5.2 According to the National Health and Nutrition Examination Survey (NHANES), about 30% of men aged ≥ 50 years have osteopenia.4 FRAX is a fracture risk assessment tool that is used to predict the 10-year risk of fracture in untreated patients with osteopenia. The FRAX tool has been validated with the use of BMD testing only at the femoral neck; it has not been validated in other parts of the body. Treatment is indicated if the 10-year fracture risk is > 20% for major osteoporotic fractures and > 3% for hip fractures, based on the FRAX calculation.2
The following risk factors are used in the FRAX calculation: age; sex; weight (kilograms); height (centimeters); previous fracture (yes or no); parental history of hip fracture (yes or no); current smoker (yes or no); oral glucocorticoid exposure currently or for > 3 months in the past (yes or no); rheumatoid arthritis (yes or no); secondary osteoporosis or a disorder strongly associated with osteoporosis, including type 1 diabetes mellitus, osteogenesis imperfecta in adults, untreated long-standing hyperthyroidism, hypogonadism, premature menopause, chronic malnutrition, malabsorption, or chronic liver disease (yes or no); 3 or more units of alcohol daily (yes or no); and BMD.5
A dual-energy X-ray absorptiometry (DXA) examination is needed to determine BMD. However, a DXA examination is not always feasible for patients who have limited access, transportation challenges, require the use of assistive devices, and may be unaware of the importance of BMD testing.
The FRAX calculation can be obtained with or without BMD. Gadam and colleagues compared FRAX calculations with and without BMD to predict the 10-year risk of fracture.6 Their study found that 84% of patients had an identical fracture risk prediction whether or not BMD was included. The only risk factor evaluated that was significantly different between those with different treatment predictions and those with identical treatment predictions was age. However, the majority of patients included were female (96%).
No studies existed that compared fracture prediction risk with and without BMD in a male-only population. The purpose of this study was to determine whether FRAX without BMD was as effective as FRAX with BMD to predict the risk of osteoporotic fractures and provide an identical treatment recommendation in male veteran patients at the Lexington VAMC in Kentucky.
Methods
A retrospective chart review was conducted at the Lexington VAMC. Approval was obtained from the Lexington VAMC Institutional Review Board and Research and Development Committee. Patients were identified using the computerized patient record system (CPRS). Included patients were male, ≥ 50 years, had a documented DXA in CPRS from January 2006 to September 2015, and had a previous fracture determined by ICD-9 codes. Patients were excluded if they were diagnosed with osteoporosis or were ever treated for osteoporosis before a DXA scan.
Data collection included patient’s age, gender, race, glucocorticoid use for at least 3 months within 1 year prior to DXA, body weight within 3 months prior to DXA, height within 1 year prior to DXA, family history of fracture, previous fall or fracture, diagnosis of rheumatoid arthritis, smoking status at the time of DXA, alcohol intake of at least 3 drinks per day at the time of DXA, and vitamin D level within 1 year prior to DXA. In order to find a clinically significant difference (P < .05) with a power of 80%, a sample size of 64 patients was needed.
Each patient’s FRAX predictions were calculated with and without BMD. Patients were then separated into 2 groups: those who had an identical treatment recommendation when calculating FRAX with and without BMD, and those who had a different treatment recommendation when calculating FRAX with and without BMD. Binary variables for each group were compared using the Fisher exact test, and numeric variables were compared using a simple Student’s t test.
Results
After screening 1,510 patients, only 119 patients met the criteria and were included in the study (Figure). All patients included were male. Mean age was 71.2 years and 113 (95.0%) were white (Table 1).