William D. Leslie, MD, MSc; Sumit R. Majumdar, MD, MPH; Suzanne N. Morin, MD, MSc; Lisa M. Lix, PhD
Note: This article has been reviewed and approved by the members of the Manitoba Bone Density Program Committee.
Disclaimer: The results and conclusions are those of the authors, and no official endorsement by the Manitoba Centre for Health Policy at the University of Manitoba, Manitoba Health, or other data providers is intended or should be inferred.
Acknowledgment: The authors thank the Manitoba Centre for Health Policy for use of data contained in the Population Health Research Data Repository (Health Information Privacy Committee Project Number 2012/2013-18) and Dr. Shuman Yang for assisting with SAS programming and figure preparation.
Financial Support: Dr. Majumdar is supported by his role as the Endowed Chair in Patient Health Management (Faculties of Medicine and Dentistry and Pharmacy and Pharmaceutical Sciences, University of Alberta). Dr. Morin is supported by her role as Scholar through Research Funds of Quebec Health. Dr. Lix is supported by her role as a Research Manitoba Chair.
Disclosures: Dr. Leslie reports grants from Amgen (paid to facility) and speaker fees (paid to facility) from Eli Lilly and Novartis outside the submitted work. Dr. Morin reports grants from Amgen and Merck (paid to institution) and personal fees from Amgen outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-2937.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement: Study protocol and data set: Not available. Statistical code: SAS code for producing directly adjusted risk estimates is available from Dr. Leslie (e-mail, firstname.lastname@example.org).
Requests for Single Reprints: William D. Leslie, MD, MSc, Department of Medicine (C5121), University of Manitoba, Winnipeg, 409 Tache Avenue, Winnipeg, Manitoba R2H 2A6, Canada; e-mail, email@example.com.
Current Author Addresses: Dr. Leslie: Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, Manitoba R2H 2A6, Canada.
Dr. Majumdar: General Internal Medicine, University of Alberta, 5-134B Clinical Sciences Building, 11350-83rd Avenue, Edmonton, Alberta T6G 2G3, Canada.
Dr. Morin: General Internal Medicine, McGill University Health Centre, Montreal General Hospital, 1650 Cedar Avenue, Room B2-118, Montréal, Québec H3G 1A4, Canada.
Dr. Lix: Department of Community Health Sciences, University of Manitoba, S113-750 Bannatyne Avenue, Winnipeg, Manitoba R3P 2H5, Canada.
Author Contributions: Conception and design: W.D. Leslie, S.R. Majumdar, L.M. Lix.
Analysis and interpretation of the data: W.D. Leslie, S.R. Majumdar, L.M. Lix.
Drafting of the article: W.D. Leslie, L.M. Lix.
Critical revision of the article for important intellectual content: W.D. Leslie, S.R. Majumdar, S.N. Morin, L.M. Lix.
Final approval of the article: W.D. Leslie, S.R. Majumdar, S.N. Morin, L.M. Lix.
Provision of study materials or patients: W.D. Leslie.
Statistical expertise: W.D. Leslie, L.M. Lix.
Obtaining of funding: W.D. Leslie.
Administrative, technical, or logistic support: W.D. Leslie.
Collection and assembly of data: W.D. Leslie.
Leslie WD, Majumdar SR, Morin SN, Lix LM. 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;165:465-472. doi: 10.7326/M15-2937
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Published: Ann Intern Med. 2016;165(7):465-472.
Published at www.annals.org on 19 July 2016
Whether change in bone mineral density (BMD) is an accurate indicator of antifracture effect in clinical practice is unknown.
To evaluate repeated BMD testing as an indicator of treatment-related fracture risk reduction.
Registry-based cohort study.
6629 women aged 40 years or older initiating osteoporosis treatment with 2 consecutive dual-energy x-ray absorptiometry scans (mean interval, 4.5 years).
Change in BMD between the first and second dual-energy x-ray absorptiometry scans categorized as stable, detectable decrease, or detectable increase. Incident fractures were ascertained from health services data.
During a mean of 9.2 years, 910 (13.7%) women developed incident fractures, including 198 with hip fractures. After adjustment for baseline fracture probability, women with a detectable decrease in total hip BMD compared with stable BMD had an absolute increase of 2.9% (95% CI, 1.5% to 4.4%) and 5.5% (CI, 2.8% to 8.1%) in the 5- and 10-year cumulative incidence of any fracture, respectively. In contrast, risk for any fracture in women with a detectable increase in total hip BMD was 1.3% (CI, 0.4% to 2.2%) and 2.6% (CI, 0.7% to 4.5%) lower after 5 and 10 years, respectively. Consistent results were seen for change in femoral neck and lumbar spine BMD and across a range of subgroup analyses.
Lack of standardization in the BMD testing interval.
Treatment-related increases in total hip BMD are associated with reduced fracture risk compared with stable BMD, whereas decreases in BMD are associated with greater risk for fractures. Monitoring BMD in clinical practice may help to identify women with a suboptimal response to osteoporosis treatment.
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