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risk of fracture

Etiology: - osteopenia - osteoporosis - multiple myeloma - bone metastases - post-menopausal weight gain or weight loss (> 5%) is associated with increased risk of bone fracture atmost, but not all sites [1] - unintentional weight loss associated with highest risk of fracture, hip fracture (RR=1.33), vertebral fracture (RR=1.33) - initiation of antihypertensive in nursing home associated with increased risk of falls & fractures [6] - risk higher among residents with dementia, higher baseline blood pressure & no recent antihypertensive use [6] - men with lower sex hormone-binding globulin (SHBG) in serum may have a lower risk of fracture than those with higher levels [7] Special laboratory: - USPSTF recommends screening for osteoporosis in all women >= 65 years & in women < 65 years who at increased risk for osteoporosis, as determined by a formal clinical risk assessment tool (FRAX & QFracture are two such tools) - FRAX fracture risk assessment tool (fee) for use in older patients uses results of DEXA scan if available in addition to clinical factors - QFracture risk calculator is free Radiology: - DEXA scan as indicated by FRAX fracture risk assessment tool - include distal 3rd of radius in patients with hyperparathyroidism [5] Management: - calcium supplements &/or dietary calcium do not significantly* increase bone mineral density or reduce risk of fractures in persons > 50 years of age [2] - calcium supplements &/or vitamin D does not reduce fracture risk in community-dwelling older adults [3] - small benefit for vitamin D & calcium together [4] - vitamin D alone of no benefit [4] * clinical significance vs statistical significance; 1-2% increase in bone mineral density not clinically significant [2]

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bone fracture FRAX fracture risk assessment tool risk for fracture communicated

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health risk factor(s)

References

  1. Crandall CJ et al. Postmenopausal weight change and incidence of fracture: Post hoc findings from Women's Health Initiative observational study and clinical trials. BMJ 2015 Jan 27; 350:h25 PMID: 25627698 http://www.bmj.com/content/350/bmj.h25
  2. Tai V et al Calcium intake and bone mineral density: systematic review and meta-analysis. BMJ 2015;351:h4183 PMID: 26420598 http://www.bmj.com/content/351/bmj.h4183 - Bolland MJ et al Calcium intake and risk of fracture: systematic review. BMJ 2015;351:h4580 PMID: 26420387 http://www.bmj.com/content/351/bmj.h4580 - Michaelsson K Calcium supplements do not prevent fractures. BMJ 2015;351:h4825 PMID: 26420735 http://www.bmj.com/content/351/bmj.h4825
  3. Zhao JG, Zeng XT, Wang J et al Association Between Calcium or Vitamin D Supplementation and Fracture Incidence in Community-Dwelling Older Adults. A Systematic Review and Meta-analysis. JAMA. 2017;318(24):2466-2482 PMID: 29279934 https://jamanetwork.com/journals/jama/article-abstract/2667071
  4. Yao P, Bennett D, Mafham M, et al. Vitamin D and calcium for the prevention of fracture: A systematic review and meta-analysis. JAMA Netw Open 2019 Dec 2; 2:e1917789 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2757873
  5. NEJM Knowledge+ Endocrinology
  6. Dave CV et al. Antihypertensive medication and fracture risk in older Veterans Health Administration nursing home residents. JAMA Intern Med 2024 Apr 22; [e-pub]. PMID: 38648065 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2818019
  7. Grahnemo L, Marriott RJ, Murray K et al Associations of Serum Testosterone and Sex Hormone-Binding Globulin with Incident Fractures in Middle-Aged to Older Men. J Clin Endocrinol Metab. 2024 Oct 7:dgae703. PMID: 39373573 https://academic.oup.com/jcem/advance-article/doi/10.1210/clinem/dgae703/7814739