Do we need bone mineral density to estimate osteoporotic fracture risk? A 10-year prospective multicentre validation study.

OBJECTIVE: Evaluate the performance of FRAX®, with and without bone mineral densitometry (BMD), in predicting the occurrence of fragility fractures over 10 years. METHODS: Participants aged ≥40 years at baseline, with a complete set of data and a minimum of 8.5 years of follow-up were identified from three cohorts (n=2626). Ten-year fracture risk at baseline were estimated with FRAX® and assessed by comparison with observed fractures and receiver operating characteristic analysis. RESULTS: During a mean (SD) follow-up of 9.12 (1.5) years, 178 participants suffered a major osteoporotic (MOP) fracture and 28 sustained a hip fracture. The predictive performance of FRAX® was superior to that of BMD alone for both MOP and hip fractures. The area under the curve (AUC) of FRAX® without BMD was 0.76 (95% CI 0.72 to 0.79) for MOP fractures and 0.78 (95% CI 0.69 to 0.86) for hip fractures. No significant improvements were found when BMD was added to clinical variables to predict either MOP (0.78, 95% CI 0.74 to 0.82, p=0.25) or hip fractures (0.79, 95% CI 0.69 to 0.89, p=0.72). AUCs for FRAX® (with and without BMD) were greater for men than for women. FRAX®, with and without BMD, tended to underestimate the number of MOP fractures and to overestimate the number of hip fractures in females. In men, the number of observed fractures were within the 95% CI of the number predicted, both with and without BMD. CONCLUSION: FRAX® without BMD provided good fracture prediction. Adding BMD to FRAX® did not improve the performance of the tool in the general population.

Multidisciplinary Portuguese recommendations on DXA request and indication to treat in the prevention of fragility fractures.

OBJECTIVE: To establish Portuguese recommendations regarding the indication to perform DXA and to initiate medication aimed at the prevention of fragility fractures. METHODS: A multidisciplinary panel, representing the full spectrum of medical specialties and patient associations devoted to osteoporosis, as well as national experts in this field and in health economics, was gathered to developed recommendations based on available evidence and expert consensus. Recently obtained data on the Portuguese epidemiologic, economic and quality-of-life aspects of fragility fractures were used to support decisions. RESULTS: 10 recommendations were developed covering the issues of whom to investigate with DXA and whom to treat with antifracture medications. Thresholds for assessment and intervention are based on the cost-effectiveness analysis of interventions at different thresholds of ten-year probability of osteoporotic fracture, calculated with the Portuguese version of FRAX® (FRAX®Port), and taking into account Portuguese epidemiologic and economic data. Limitations of FRAX® are highlighted and guidance for appropriate adjustment is provided, when possible. CONCLUSIONS: Cost-effectiveness thresholds for DXA examination and drug intervention aiming at fragility fracture prevention are now provided for the Portuguese population. These are practical, based on national epidemiological and economic data, evidence-based and supported by a wide scope multidisciplinary panel of experts and scientific societies. Implementation of these recommendations holds great promise in assuring the most effective use of health resources in the prevention of osteoporotic fractures in Portugal.

A FRAX model for the estimation of osteoporotic fracture probability in Portugal.

INTRODUCTION: The objective of this study was to develop a Portuguese version of the World Health Organization fracture risk assessment tool (FRAX®). METHODS: All cases of hip fracture occurred at or after 40 years of age were extracted from the Portuguese National Hospital Discharge Register from 2006 to 2010. Age and sex-ranked population estimates and mortality rates were obtained from National Statistics. Age- and gender stratified incidences were computed and the average of the five years under consideration was taken. Rates for other major fractures were imputed from the epidemiology of Sweden, as undertaken for most national FRAX® models. All methodological aspects and results were submitted to critical appraisal by a wide panel of national experts and representatives of the different stakeholders, including patients. RESULTS: Hip fracture incidence rates were higher in women than in men and increased with age. The lowest incidence was observed in 40-44 years group (14.1 and 4.0 per 100,000 inhabitants for men and women, respectively). The highest rate was observed among the 95-100 age-group (2,577.6 and 3,551.8/100,000 inhabitants, for men and women, respectively). The estimated ten-year probability for major osteoporotic fracture or hip fracture increased with decreasing T-score and with increasing age. CONCLUSIONS: Portugal has one of the lowest fracture incidences among European countries. The FRAX® tool has been successfully calibrated to the Portuguese population, and can now be used to estimate the ten-year risk of osteoporotic fractures in this country. All major stakeholders officially endorsed the Portuguese FRAX® model and co-authored this paper.

[Portuguese recommendations for pain management by pharmocotherapy in inflammatory arthritis]. / Recomendações portuguesas para o tratamento e controlo farmacológico da dor nas artropatias inflamatórias.

OBJECTIVES: To develop Portuguese evidence-based recommendations for pain management by pharmocotherapy in inflammatory arthritis. METHODS: The Portuguese project was integrated in the multinational 3E Initiative (Evidence, Expertise, Exchange) 2010 where a total of 453 rheumatologists from 17 countries have participated. The clinical questions concerning pain were formulated and the Portuguese group added 2 more questions. A systematic literature search was performed in Medline, Embase, Cochrane Library and 2008-2009 EULAR and ACR abstracts. The selected articles were systematically reviewed and the evidence was defined according to the Oxford Levels of Evidence. In each country a group of experts joined to discuss their national recommendations. In Portugal, the national meeting was held in October 2010, where 33 rheumatologists discussed and voted by Delphi method the national recommendations. Finally, the agreement among the rheumatologists and the potential impact on their clinical practice was assessed. RESULTS: Thirteen national recommendations were formulated: pain measure scores; analgesic combination therapy; pharmacotherapy in preconception, pregnancy and lactation periods; pharmacotherapy according to comorbilities; safety of NSAIDs and/or paracetamol with methotrexate combination therapy; efficacy and safety of continuous/on-demand NSAIDs; opioids, paracetamol, corticosteroids, antidepressants, neuromodulators and muscle relaxants role and effectiveness; risk factors for the development of chronic pain and the role of topic analgesics. CONCLUSION: The portuguese recommendations for the pain management by pharmacotherapy in inflammatory arthritis were formulated according to the best evidence and supported by a panel of 63 rheumatologists. The differences between the national and international recommendations are reported in this article.

[Analgesic prescription habits in a population of patients with chronic rheumatic disease]. / Hábitos de prescrição anti-álgica numa população de doentes com patología crónica reumatológica.

OBJECTIVES: The aim of this study was to record the analgesic prescription commonly performed by Portuguese Rheumatologists in patients with chronic Rheumatologic disease, using the guidelines provided by the World Health Organization for treatment of chronic pain as comparative. MATERIAL AND METHODS: We randomly selected the clinical records of 203 patients with complete clinical record. We excluded patients with less than a year of follow-up, last consultations over a year ago, age under 16 years, patients with no rheumatologic diagnose, being the final sample of 94 patients. The items collected were gender, age, primary diagnosis, prescribed drugs (paracetamol, nonsteroidal anti-inflammatory steroids, glucocorticoids, tricyclic antidepressants, selective serotonin reuptake inhibitors - paroxetine and fluoxetine, anticonvulsants - gabapentin and pregabalin, colchicine and muscle relaxers with pain modulator effects of, weak and strong opioids), degree of pain (0-10). RESULTS: 84.94% of patients were female and 15.06% male. The average age was 51.5 years, men's average was 54.0 years and women 51.1 years. Overall prescription of paracetamol was 23.4% and 8.5% for tramadol (always associated with paracetamol). In 17% of patients paracetamol was added successfully. The use of various antiinflammatory agents reached a prevalence of 80.9%. Other agents were also used either Glucocorticoids - Deflazacort and prednisolone - (36.2%), tricyclic antidepressants with expressed antalgic intention (6.4%). CONCLUSIONS: There was a discrepancy between the prescription and the current indications of WHO for the control of chronic pain. This discrepancy raises the possibility of failure of some pharmacological agents in this type of pain and/or lack of systematization of analgesic therapy. We recommend further studies to prove the hypothesis.

Portuguese guidelines for the use of biological agents in rheumatoid arthritis - October 2011 update.

The authors present the revised version of the Portuguese Society of Rheumatology (SPR) guidelines for the treatment of Rheumatoid Arthritis (RA) with biological therapies. In these guidelines the criteria for introduction and maintenance of biological agents are discussed as well as the contraindications and procedures in the case of nonresponders. Biological treatment (with a tumour necrosis factor antagonist, abatacept or tocilizumab) should be considered in RA patients with a disease activity score 28 (DAS 28) equal to or greater than 3.2 despite treatment with at least 20mg-weekly-dose of methotrexate (MTX) for at least 3 months or, if such treatment is not possible, after 3 months of other conventional disease modifying drug or combination therapy. A DAS 28 score between 2.6 and 3.2 with a significant functional or radiological deterioration under treatment with conventional regimens could also constitute an indication for biological treatment. The treatment goal should be remission or, if that is not achievable, at least a low disease activity, defined by a DAS28 lower than 3.2, without significative functional or radiological worsening. The response criteria, at the end of the first 3 months of treatment, are a decrease of at least 0.6 in the DAS28 score. After 6 months of treatment res­ponse criteria is defined as a decrease greater than 1.2 in the DAS28 score. Non-responders, in accordance to the Rheumatologist's clinical opinion, should try a switch to another biological agent (tumour necrosis factor antagonist, abatacept, rituximab or tocilizumab).

[Recommendations for the diagnosis and management of osteoporosis]. / Recomendações para o diagnóstico e terapêutica da osteopordse.

This article presents the guidelines for the management of osteoporosis established by the Portuguese Society of Rheumatology and the Portuguese Society of Metabolic Bone Diseases. The document is the result of the consensus achieved after systematic review of the literature and open discussion in nationa meetings of both societies of draft documents presented by the authors. The recommendations include aspects related to diagnosis, clinical evaluation, prevention, treatment and monitoring of post-menopausal and male osteoporosis. The guidelines aim to achieve the reduction of osteoporotic fractures throug validated clinical practices that will allow the correct use of diagnostic and therapeutic resources. The consensus will be reviewed as needed whenever new scientific evidence is available.