Defining High Risk of Osteoporotic Fracture A Cross Talk Between Clinical Experience and Guidelines Recommendations Enrique Casado, MD,* Jorge Malouf, MD,Þ Manuel M. Caaman ˜o, MD,þ Esteban Salas, MD,§ Juan M. Sa ´nchez-Burso ´n, MD,|| Marı ´a L. Rentero, MD,¶ and Gabriel Herrero-Beaumont, MD# Background: There is no universally accepted definition for patients at high risk of osteoporotic fracture. Objectives: This study aimed to survey Spanish rheumatologists; to obtain opinions about risk factors, and an acceptable definition for patients at high risk of osteoporotic fracture; and to compare daily practice patterns with current osteoporosis guidelines. Methods: A total of 174 rheumatologists from throughout Spain completed an online survey about various risk factors for fragility frac- ture and about the management of patients with osteoporosis in clinical practice. Results were reviewed by a coordinating committee of osteo- porosis experts and were compared with published national and inter- national guideline recommendations. Results: Almost all rheumatologists who completed the survey (99%) consider that a group of patients exists with a high risk of osteoporotic fracture and that this group should be managed appropriately. Previous fracture is considered the most important risk factor, particularly in cases of multiple fracture, severe vertebral fracture, hip fracture, or fracture despite osteoporosis treatment. However, in osteoporosis guidelines, age, bone mineral density, and previous fragility fracture are the most important risk factors for new fracture. Furthermore, Spanish rheumatol- ogists tend to treat patients at high risk of fracture with anabolic therapy (e.g., teriparatide), whereas guidelines make no such recommendation. Conclusions: In osteoporosis, a large gap exists between implemen- tation of guideline recommendations and actual clinical practice; this may be due, in part, to heterogeneity among existing guidelines. Thus, inclusion in guidelines of a practical definition of high risk of osteopo- rotic fracture may provide significant opportunities to improve patient care and prevent future fragility fractures. Key Points: & In osteoporosis, there is a gap between guideline recom- mendations and current clinical practice regarding the iden- tification of risk factors for future fracture. & Lack of consensus about ‘high risk’ definition between available guidelines, and difficulties in interpreting guideline recommendations, may contribute to this gap between rheu- matologists’ practice and guidelines. & Patients at high risk of fracture are detected too late, thus leading to suboptimal health care delivery. & Defining a clinical profile for high-risk patients provides an opportunity to facilitate the decision-making process and im- prove patient care in osteoporosis. Key Words: fracture, health care survey, high risk, osteoporosis, risk factors (J Clin Rheumatol 2011;17: S59YS66) O steoporosis is a progressive systemic skeletal disease char- acterized by low bone mass and deterioration of bone tissue microarchitecture, with a subsequent increase in bone fragility and susceptibility to fracture. 1 The most common osteoporotic fractures are localized in spine, hip, forearm, and proximal hu- merus and constitute a major source of economic and social burden owing to a lack of diagnosis and appropriate care 2 ; such fractures contribute significantly to decreased quality of life and increased morbidity and mortality. 3Y5 Annually, more than 4.5 million fractures occur in Europe, the United States, Canada and Latin America. 6 Treatment of osteoporosis reduces the risk of future fractures; therefore, identification of patients at high risk of fractures is the first step in preventing future fractures. The World Health Organization’s definition of osteoporosis is based solely on bone mineral density (BMD) 6 because BMD seems to be the best predictor of fracture. In fact, BMD assess- ment provides both diagnostic and intervention thresholds for patients with osteoporosis and also provides information about the risk of future fractures. 6Y8 However, BMD is not the only fracture predictor; other factors have been shown to contribute to overall fracture risk. 7 Thus, there is general consensus that identification of validated risk factors, other than BMD, may help to improve the identification of patients at high risk of fracture. 9 Some clinical risk factors for fracture, independent of BMD, include previous fracture, 10 family history of hip fracture, 11 alcohol intake, 12 previous corticosteroid use, 13 and smoking. 14 Other known risk factors include age, sex, and physical inactivity. 6 Given the need to find a better system to predict fracture risk (i.e., a system that could combine BMD and other clinical risk factors), several prediction models have recently been devel- oped. The FRAX tool is the best known. 15 Developed by the World Health Organization, this tool evaluates fracture risk by integrating clinical risk factors and femoral neck BMD. Al- though this tool is more comprehensive than BMD alone for assessing fracture risk, it has several limitations and is still not validated in most countries. Despite improved knowledge of the various risk factors for fragility fracture, and the large number of published guidelines, SUPPLEMENT JCR: Journal of Clinical Rheumatology & Volume 17, Number 5, August Supplement 3 2011 www.jclinrheum.com S59 From the *Department of Rheumatology, Hospital de Sabadell, Corpo- racio ´ Sanita `ria i Universita `ria Parc Taulı ´, Sabadell, Barcelona; †Department of Internal Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona; ‡Department of Rheumatology, Hospital Clı ´nico Universitario Santiago de Compostela, Galicia; §Department of Rheumatology, Hospital Uni- versitario de San Juan de Alicante, Alicante; ||Department of Rheuma- tology, Hospital Universitario Nuestra Sen ˜ora de Valme, Sevilla; ¶Bone Metabolism Unit, Medical Department, Lilly Spain; and LDepartment of Rheumatology, Fundacio ´n Jime ´nez Dı ´az, Madrid, Spain. This study was supported by Eli Lilly and Company, Spain. The authors thank Dr Ximena Alvira and Soledad Santos, who provided medical writing assistance on behalf of inScience Communications, a Wolters Kluwer business. This assistance was funded by Eli Lilly and Company, Spain. The authors declare no conflicts of interest. Correspondence: Enrique Casado, MD, Hospital de Sabadell, Corporacio ´ Sanita `ria i Universita `ria Parc Taulı ´, Parc Taulı ´, s/n-08208 Sabadell, Barcelona, Spain. E-mail: ecasado@tauli.cat. Phone: +34 937231010 Fax: +34 937160646. Copyright * 2011 by Lippincott Williams & Wilkins ISSN: 1076-1608/11/1705Y0S59 DOI: 10.1097/RHU.0b013e318227a106 Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.