國外骨折風險評估工具FRAX的應(yīng)用進展

國外骨折風險評估工具FRAX的應(yīng)用進展摘要：骨質(zhì)疏松性骨折是骨質(zhì)疏松最嚴重的后果，世界衛(wèi)生組織推薦使用簡單易行的骨折風險預測工具FRAX評估患者的骨折風險，針對高風險人群進行及時干預，大大降低其危害。國外有關(guān)FRAX應(yīng)用研究逐漸精細和深入，有關(guān)FRAX在不同疾病患者中的適用性，及結(jié)合、不結(jié)合股骨頸BMD對FRAX預測結(jié)果影響的研究逐漸增多。本文就FRAX在國外類風濕關(guān)節(jié)炎、絕經(jīng)后女性和糖尿病患者中的應(yīng)用現(xiàn)狀進行綜述，F(xiàn)RAX在不同病種的應(yīng)用為臨床醫(yī)生及護士積極采取防治及護理措施提供決策和依據(jù)。關(guān)鍵詞：骨質(zhì)疏松性骨折；骨折風險性；風險因子；FRAXApplicationprogressoffractureriskassessmenttoolFRAXinforeigncountriesLIUSuxiangTheFourthAffiliatedHospitalofZhejiangUniversityMedicalCollegeAbstract:Osteoporoticfractureisthemostseriousconsequenceofosteoporosis,theWorldHealthOrganizationrecommendstheuseofsimplefractureriskpredictiontoolsFRAX,timelyinterventionforhigh-riskgroupscangreatlyreducetheharm.Inforeigncountries,theapplicationstudyofFRAXgraduallyelaborateandin-depth,thestudyofFRAXscorescalculatedwithorwithoutfemoralneckbonemineral

densitygraduallyincrease.ThisarticlereviewstheapplicationstatusofFRAXinrheumatoidarthritis,postmenopausalwomenandpatientswithdiabetesmellitus.FRAXapplicationsindifferentkindsofdiseaseprovidedecision-makingandbasisforclinicaldoctorsandnursestotakeactivemeasures.Keywords:Osteoporoticfracture;Fracturerisk;Riskfactors;FRAX骨質(zhì)疏松（osteoporosis，OP）是以骨量減少、骨的微觀結(jié)構(gòu)退化為特征的，致使骨的脆性增加以及易于發(fā)生骨折的全身性骨骼疾病[[]CarlssonL,JohnsonCS.OsteoporosishealthbeliefsandpracticesamongKoreanimmigrantsinNovaScotia[J].JournalofImmigrantHealth,2004,6(2):93-100.]。發(fā)生骨質(zhì)疏松性骨折（osteoporosisfracture，OF）是OP最嚴重的后果，其具有高發(fā)病率、高死亡率的特點[[]CauleyJA,ChalhoubD,KassemAM,etal.Geographicandethnicdisparitiesinosteoporoticfractures.NatRevEndocrinol,2014,10(6),338-351.]，有研究預計到2025年歐洲人群之中每年發(fā)生OF的次數(shù)可達450萬次[[]KanisJA,Borgstr?mF,CompstonJ,etal.SCOPE:ascorecardforosteoporosisinEurope.ArchOsteoporos,2013,8,144.]，由OF產(chǎn)生的直接費用在美國為190億美元[[][]CarlssonL,JohnsonCS.OsteoporosishealthbeliefsandpracticesamongKoreanimmigrantsinNovaScotia[J].JournalofImmigrantHealth,2004,6(2):93-100.[]CauleyJA,ChalhoubD,KassemAM,etal.Geographicandethnicdisparitiesinosteoporoticfractures.NatRevEndocrinol,2014,10(6),338-351.[]KanisJA,Borgstr?mF,CompstonJ,etal.SCOPE:ascorecardforosteoporosisinEurope.ArchOsteoporos,2013,8,144.[]BurgeR,Dawson-HughesB,SolomonDH,etal.Incidenceandeconomicburdenofosteoporosis-relatedfracturesintheUnitedStates,2005-2025.JBoneMinerRes,2007,22(3),465-475.Frax簡介骨折風險評估工具(fractureriskassessmenttool，F(xiàn)RAX)是由英國Kanis教授等人在2008年研發(fā)的一種計算骨折風險的評估工具，該工具是根據(jù)骨折危險因素和股骨頸骨密度（bonemineraldensity，BMD），通過一系列大樣本循證醫(yī)學原始數(shù)據(jù)計算建立，用來評價未來10年骨質(zhì)疏松性骨折風險的一個計算機評估軟件[[]KanisJA,BorgstromF,DeLactC,etal.AssessmentofFracturerisk.OsteoporosInt,2005，16:581-589．]

。該工具納入了年齡、性別、身高、體重、及其他7個骨折風險因子：既往低能量骨折史、雙親髖部骨折史、吸煙、長期服用糖皮質(zhì)激素藥物、風濕性關(guān)節(jié)炎病史、每日飲酒量和繼發(fā)性骨質(zhì)疏松。同時可以在軟件中選擇輸入股骨頸BMD來提高其風險預測值。FRAX中骨折相關(guān)危險因素是通過對北美、歐洲、亞洲、澳洲等多個獨立的大樣本的前瞻性人群研究的原始資料和大樣本薈萃分析后確定的，因此是有共性的。但FRAX計算模型中還需要相應(yīng)國家人群的骨折發(fā)生率和人群死亡率的流行病學資料，已知骨折發(fā)生率和人群死亡率流行病學資料的國家和地區(qū)已經(jīng)對FRAX進行了校準[[]KanisJA,JohnellO,DeLaetC,etal.Internationalvariationsinhipfractureprobabilities:implicationsforriskassessment.JBoneMinerRes,2002,17:1237-1244.]，WHO建議那些沒有本國資料的國家和地區(qū)可使用與自己國家最接近的計算工具，同樣具有良好參考價值。目前FRAX可應(yīng)用于31個國家和地區(qū)，并提供13種語言支持。美國指南中骨質(zhì)疏松性骨折高風險患者標準:10年主要部位OF發(fā)生概率≥20%或10年髖部骨折發(fā)生概率≥3%，針對這些高風險患者及時干預，而且FRAX可以不結(jié)合BMD進行骨折風險評估，在一些骨密度檢測儀器稀缺地區(qū)也可以應(yīng)用[[]KanisJA,McCloskeyEV,JohanssonH,etal.FRAX?withandwithoutBoneMineralDensity.CalcifiedTissueInternational,2012,[]KanisJA,BorgstromF,DeLactC,etal.AssessmentofFracturerisk.OsteoporosInt,2005，16:581-589．[]KanisJA,JohnellO,DeLaetC,etal.Internationalvariationsinhipfractureprobabilities:implicationsforriskassessment.JBoneMinerRes,2002,17:1237-1244.[]KanisJA,McCloskeyEV,JohanssonH,etal.FRAX?withandwithoutBoneMineralDensity.CalcifiedTissueInternational,2012,90:1-13.[]MarquesA,

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SantosE,etal.Theaccuracyofosteoporoticfractureriskpredictiontools:asystematicreviewandmeta-analysis.\o"Annalsoftherheumaticdiseases."AnnRheumDis,2015,74(11):1958-1967.2在類風濕關(guān)節(jié)炎患者中的應(yīng)用類風濕關(guān)節(jié)炎患者（

rheumatoidarthritis，RA）的常見并發(fā)癥是低BMD，可引起OP或骨量減少，早在2000年國外學者Haugeberg等[[]HaugebergG,UhligT,FilchJA,etal.Bonemineraldensityandfrequencyofosteoporosisinfemalepatientswithrheumatoidarthritis:resultfrom394patientsintheOlsocountyrheumatoidarthritisregister.ArthritisRheum,2000,43(7):522-530.]報道發(fā)現(xiàn)RA患者中OP的發(fā)生率是正常人的2倍。Curtis等[[]CurtisJR,AroraT,DonaldsonM,etal.SkeletalHealthamongAfricanAmericanswithRecentOnsetRheumatoidArthritis[J].ArthritisRheum,2009,61(10):1379-1386．]對324名非洲裔美國RA患者的研究發(fā)現(xiàn)，RA患者的骨折風險在逐年增加，而應(yīng)用FRAX工具在RA患者中篩選出的高危骨折人群，可以對其進行有針對性的檢查及治療。Lee等[[]LeeJH,

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2014,81(4):347-351.3在絕經(jīng)后女性患者中的應(yīng)用女性絕經(jīng)后OP及其引起的骨折發(fā)病率越來越高。Catalano等[[]CatalanoA,

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BasileG,etal.FractureriskassessmentinpostmenopausalwomenreferredtoanItaliancenterforosteoporosis:asingledayexperienceinMessina.\o"Clinicalcasesinmineralandbonemetabolism:theofficialjournaloftheItalianSocietyofOsteoporosis,MineralMetabolism,andSkeletalDiseases."ClinCasesMinerBoneMetab,2013,10(3):191-194.]將80名絕經(jīng)后女性劃分為[]CatalanoA,

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BasileG,etal.FractureriskassessmentinpostmenopausalwomenreferredtoanItaliancenterforosteoporosis:asingledayexperienceinMessina.\o"Clinicalcasesinmineralandbonemetabolism:theofficialjournaloftheItalianSocietyofOsteoporosis,MineralMetabolism,andSkeletalDiseases."ClinCasesMinerBoneMetab,2013,10(3):191-194.Sarikaya等[[]OlmezSarikayaN,KaparYavasiS,TanG,etal.Agreement

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bonemineral

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women

withosteopenia

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]發(fā)現(xiàn)，結(jié)合與不結(jié)合BMD比較，絕經(jīng)后女性髖部骨折高風險人群比例降低，與Yoon等[[]YoonDH,ChoiDH,JungHG,etal.Howmanyhighriskkoreanpatientswithosteopeniacouldoverlooktreatmenteligibility?AsianSpineJ,2014,8(6):729-734.]研究結(jié)果一致，Ilias等[[]IliasI,SpanoudiF,KoukkouE,etal.UseoftheFRAXcalculatorwithandwithoutbonemineraldensityinGreekwomen.Hormones(Athens),2012,11(2):222-223.]對希臘女性研究發(fā)現(xiàn)，結(jié)合與不結(jié)合BMD比較，髖部骨折高風險人群比例升高，分析原因可能為研究者們均無基于本國的FRAX模式，均使用基于意大利流行病學資料的FRAX模式。Bastos-Silva等[[]Bastos-SilvaY,AguiarLB,Pinto-NetoAM,etal.CorrelationbetweenosteoporoticfractureriskinBrazilianpostmenopausalwomencalculatedusingtheFRAXwithandwithouttheinclusionofbonedensitometrydata.\o"Archivesofosteoporosis."ArchOsteoporos,2016,11(1):16.

[]OlmezSarikayaN,KaparYavasiS,TanG,etal.Agreement

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bonemineral

density

in

women

withosteopenia

in

Turkey.\o"Clinicalrheumatology."ClinRheumatol,2014,33(12):1785-1789.

[]YoonDH,ChoiDH,JungHG,etal.Howmanyhighriskkoreanpatientswithosteopeniacouldoverlooktreatmenteligibility?AsianSpineJ,2014,8(6):729-734.[]IliasI,SpanoudiF,KoukkouE,etal.UseoftheFRAXcalculatorwithandwithoutbonemineraldensityinGreekwomen.Hormones(Athens),2012,11(2):222-223.[]Bastos-SilvaY,AguiarLB,Pinto-NetoAM,etal.CorrelationbetweenosteoporoticfractureriskinBrazilianpostmenopausalwomencalculatedusingtheFRAXwithandwithouttheinclusionofbonedensitometrydata.\o"Archivesofosteoporosis."ArchOsteoporos,2016,11(1):16.

[]BansalS,PecinaJL,MerrySP,etal.USPreventativeServicesTaskForce

FRAX

thresholdhasalowsensitivitytodetectosteoporosisin

womenages50-64years.OsteoporosInt,2015,26(4):1429-1433.4在糖尿病患者中的應(yīng)用相關(guān)證據(jù)表明：糖尿病影響骨骼代謝，長期高血糖水平對骨骼的副作用應(yīng)視為糖尿病嚴重并發(fā)癥。傳統(tǒng)上僅認為1型糖尿病可以增加骨折風險[[]DedeAD,

TournisS,

DontasI,etal.Type2

diabetesmellitus

andfracturerisk.\o"Metabolism:clinicalandexperimental."Metabolism,2014,63(12):1480-1490.]，隨著近年來2型糖尿病患病率增加，有關(guān)2型糖尿病與骨折風險關(guān)系的研究引起學者們極大關(guān)注。Ma等[[]MaL,OeiL,JiangL,etal.Associationbetweenbonemineraldensityandtype2diabetesmellitus:ameta-analysisofobservationalstudies.EurJEpidemiol,2012,27(5):319-332.]研究發(fā)現(xiàn)，與對照組健康人群相比，2型糖尿病患者在股骨頸、髖部和椎體部位BMD較高，另外一些學者發(fā)現(xiàn)，2型糖尿病患者BMD較對照組低或者近似[[]YaturuS,HumphreyS,LandryC,etal.Decreasedbonemineraldensityinmenwithmetabolicsyndromealoneandwithtype2diabetes.MedSciMonit,2009,15(1):CR5-9.-[]McKennaMJ.Bone

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]。Schwartz等[[]SchwartzAV,VittinghoffE,BauerDC,etal.AssociationofBMDandFRAXscorewithriskoffractureinolderadultswithtype2diabetes[J].JAMA,2011[]DedeAD,

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andfracturerisk.\o"Metabolism:clinicalandexperimental."Metabolism,2014,63(12):1480-1490.[]MaL,OeiL,JiangL,etal.Associationbetweenbonemineraldensityandtype2diabetesmellitus:ameta-analysisofobservationalstudies.EurJEpidemiol,2012,27(5):319-332.[]YaturuS,HumphreyS,LandryC,etal.Decreasedbonemineraldensityinmenwithmetabolicsyndromealoneandwithtype2diabetes.MedSciMonit,2009,15(1):CR5-9.[]McKennaMJ.Bone

mineral

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non-insulin-dependent