Available online 7 January 2023

Author links open overlay panelABSTRACT

Trabecular bone score (TBS) predicts osteoporotic fractures independent of bone mineral density (BMD) and clinical risk factors. The aim of this study was to explore whether anti-resorptive treatment affects fracture risk prediction from TBS using a large clinical registry that includes all dual-energy X-ray absorptiometry (DXA) tests for the Province of Manitoba, Canada. Cohort 1 included 53,863 individuals aged ≥ 40 years (11.4% men; mean age 64.1 years) who had not received any anti-resorptive therapy in the year prior the baseline DXA. Cohort 2 comprised 22,917 individuals aged ≥ 40 years (6% men, mean age 66.7 years) undergoing a second DXA visit. Anti-resorptive medication was initiated in the first year after DXA in 13,439 (25%) individuals from Cohort 1 (87.9% bisphosphonates); among Cohort 2 8,864 (38.7%) had received anti-resorptive medication in the year before DXA (77.8% bisphosphonates). Incident major osteoporotic fracture (MOF), hip fracture and any fracture were identified over mean follow up 8.6 and 7.0 years for Cohorts 1 and 2, respectively. Area under the curve showed significant risk stratification for all fracture types and treatment levels, whether treatment was initiated after TBS measurement (Cohort 1) or prior to TBS measurement (Cohort 2). In Cox regression models, without and with covariate adjustment, fracture prediction from TBS was unaffected by anti-resorptive medication use (p-interaction >0.5 for all analyses). In conclusion, TBS was a robust predictor of fracture in models adjusted for clinical risk factors and BMD. The use of anti-resorptive therapy, either in the year before or following TBS measurement, did not attenuate fracture risk prediction by TBS compared to untreated individuals.

Section snippetsINTRODUCTION

Since its introduction more than 30 years ago, dual-energy X-ray absorptiometry (DXA) has been widely used to select patients for anti-osteoporosis therapy1, 2, 3. Reassessment of bone mineral density (BMD) during or following a course of therapy is also commonly performed in clinical practice, though this remains more controversial and is not universally supported4. BMD is responsive to anti-osteoporosis therapy, with larger increases being associated with greater anti-fracture effect5, 6, 7.

Study population

In Canada, health services including DXA testing are provided to nearly all residents through a single public health care system15. DXA testing through the Manitoba Density Program has been managed as an integrated program since 199716. The Manitoba Density Program maintains a database of all DXA results that can be linked with other population-based databases through an anonymous personal identifier. The associated database exceeds 99% in terms of completeness and accuracy17.

For the current

RESULTS

The study population characteristics are summarized in Table 1. In total there were 53,863 individuals in Cohort 1 for analysis of anti-resorptive treatment initiated after visit 1, and 22,917 in Cohort 2 for analysis of anti-resorptive treatment before visit 2. Mean age were 64.1±10.8 years and 66.7± 9.9 years, with a large predominance of females, typical for the patients undergoing screening DXA. Among Cohort 1, 25.0% initiated anti-resorptive treatment after visit 1, 87.9% bisphosphonate.

DISCUSSION

We found that TBS is a robust predictor of incident MOF, hip fracture and any fracture in analyses that adjusted for multiple covariates including BMD. Importantly, TBS continued to predict fracture risk in individuals newly initiating anti-resorptive therapy and in individuals recently receiving anti-resorptive therapy, without any attenuation in risk prediction compared with untreated individuals, and no significant interaction between TBS and treatment adherence. This suggests that TBS can

Funding

No funding support was received for this research project.

Disclosures

William Leslie and Barbara Silva declare no conflict of interest.

Didier Hans: Co-ownership in the TBS patent. Stock options or royalties: Med-Imaps. Research grants: Amgen, Agnovos, GE Healthcare.

Roles

Authors' roles: conception, design, data analysis, drafting the article (WDL), interpretation of data (All Authors); critically revising the article for important intellectual content (All Authors); final approval of the version to be published (All Authors); and agreement to be accountable for all aspects of the work (All Authors). WDL had full access to all the data in the study and takes the responsibility for the integrity of the data and the accuracy of the data analysis.

Acknowledgments

The authors acknowledge the Manitoba Centre for Health Policy for use of data contained in the Population Health Research Data Repository (HIPC 2016/2017- 29). The results and conclusions are those of the authors and no official endorsement by the Manitoba Centre for Health Policy, Manitoba Health, Healthy Living, and Seniors, or other data providers is intended or should be inferred. This article has been reviewed and approved by the members of the Manitoba Bone Density Program Committee.

REFERENCES (24)WD Leslie et al.Change in Bone Mineral Density Is an Indicator of Treatment-Related Antifracture Effect in Routine Clinical Practice: A Registry-Based Cohort Study

Ann Intern Med

(2016)

J Banefelt et al.Total Hip Bone Mineral Density as an Indicator of Fracture Risk in Bisphosphonate-Treated Patients in a Real-World Setting

J Bone Miner Res

(2021)

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© 2023 The International Society for Clinical Densitometry. Published by Elsevier Inc.