El-Hajj Fuleihan Ghada, Chakhtoura Marlene, Cauley Jane A, Chamoun Nariman
Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, Division of Endocrinology and Metabolism, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, Division of Endocrinology and Metabolism, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
J Clin Densitom. 2017 Jul-Sep;20(3):397-424. doi: 10.1016/j.jocd.2017.06.008. Epub 2017 Jul 19.
The substantial increase in the burden of non-communicable diseases in general and osteoporosis in particular, necessitates the establishment of efficient and targeted diagnosis and treatment strategies. This chapter reviews and compares different tools for osteoporosis screening and diagnosis; it also provides an overview of different treatment guidelines adopted by countries worldwide. While access to dual-energy X-ray absorptiometry to measure bone mineral density (BMD) is limited in most areas in the world, the introduction of risk calculators that combine risk factors, with or without BMD, have resulted in a paradigm shift in osteoporosis screening and management. To-date, forty eight risk assessment tools that allow risk stratification of patients are available, however only few are externally validated and tested in a population-based setting. These include Osteoporosis Self-Assessment Tool; Osteoporosis Risk Assessment Instrument; Simple Calculated Osteoporosis Risk Estimation; Canadian Association of Radiologists and Osteoporosis Canada calculator; Fracture Risk Assessment Calculator (FRAX); Garvan; and QFracture. These tools vary in the number of risk factors incorporated. We present a detailed analysis of the development, characteristics, validation, performance, advantages and limitations of these tools. The World Health Organization proposes a dual-energy X-ray absorptiometry-BMD T-score ≤ -2.5 as an operational diagnostic threshold for osteoporosis, and many countries have also adopted this cut-off as an intervention threshold in their treatment guidelines. With the introduction of the new fracture assessment calculators, many countries chose to include fracture risk as one of the major criteria to initiate osteoporosis treatment. Of the 52 national guidelines identified in 36 countries, 30 included FRAX derived risk in their intervention threshold and 22 were non-FRAX based. No universal tool or guideline approach will address the needs of all countries worldwide. Osteoporosis screening and management guidelines are best tailored according to the needs and resources of individual counties. While few countries have succeeded in generating valuable epidemiological data on osteoporotic fractures, to validate their risk calculators and base their guidelines, many have yet to find the resources to assess variations and secular trends in fractures, the performance of various calculators, and ultimately adopt the most convenient care pathway algorithms.
总体而言，非传染性疾病负担大幅增加，尤其是骨质疏松症，这就需要制定高效且有针对性的诊断和治疗策略。本章回顾并比较了骨质疏松症筛查和诊断的不同工具；还概述了世界各国采用的不同治疗指南。虽然在世界上大多数地区，使用双能X线吸收法测量骨密度（BMD）的机会有限，但引入结合了风险因素（有或无BMD）的风险计算器，已导致骨质疏松症筛查和管理发生了范式转变。迄今为止，有48种可对患者进行风险分层的风险评估工具，但只有少数经过外部验证并在基于人群的环境中进行了测试。这些工具包括骨质疏松症自我评估工具；骨质疏松症风险评估工具；简易计算骨质疏松症风险估计；加拿大放射学会和加拿大骨质疏松症计算器；骨折风险评估计算器（FRAX）；加尔万；以及QFracture。这些工具纳入的风险因素数量各不相同。我们对这些工具的开发、特点、验证、性能、优点和局限性进行了详细分析。世界卫生组织建议将双能X线吸收法测定的骨密度T值≤ -2.5作为骨质疏松症的操作诊断阈值，许多国家也在其治疗指南中采用了这一切点作为干预阈值。随着新的骨折评估计算器的引入，许多国家选择将骨折风险作为启动骨质疏松症治疗的主要标准之一。在36个国家确定的52项国家指南中，30项在其干预阈值中纳入了FRAX得出的风险，22项基于非FRAX。没有一种通用工具或指南方法能满足世界所有国家的需求。骨质疏松症筛查和管理指南最好根据各个国家的需求和资源进行量身定制。虽然很少有国家成功生成有关骨质疏松性骨折的有价值的流行病学数据，以验证其风险计算器并为其指南提供依据，但许多国家尚未找到资源来评估骨折的变化和长期趋势、各种计算器的性能，并最终采用最便捷的护理途径算法。
