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Imminent Risk

Jonathan D. Adachi MD, FRCPC

The Actavis Chair in Rheumatology for Better Bone Health Professor, Department of Medicine Michael G. DeGroote School of Medicine St. Joseph’s Healthcare – McMaster University Hamilton, Ontario.

  • Background

    What do we mean by imminent fracture risk?

    Fractures are to people with osteoporosis what heart attacks are to people with cardiovascular disease.

    Fractures are bone attacks and should be considered a medical emergency for the osteoporotic patient. Hip and vertebral fractures are associated with increased risk of mortality.1 The Canadian Osteoporosis Multicentre Study (CaMOS) demonstrated that patients with vertebral fracture or hip fracture were at approximately three times greater risk of death than those without fractures.1

    Imminent fracture risk means exactly that – using risk assessment to identify those patients who are at high risk of an imminent (with 12-24 months) fracture.2

    How do we identify patients at risk of imminent fracture?

    It is well documented that initial fracture, in particular hip and spine fracture identifies those at high risk for subsequent fracture in the next 12 to 24 months (imminently).3 Advancing age and bone mineral density (BMD) are also important risk factors contributing to imminent fracture risk.3 Practice guidelines recommend BMD assessment within one-year post-index fracture to re-assess fracture risk.4-6 However, a Canadian cohort study demonstrated that only 16.4% of patients underwent a BMD assessment one-year post-index fracture.3

    In clinical practice, tools such as flowsheets are useful to help identify patients at imminent fracture risk as they help us to systematically compile relevant patient data. Validated tools, such as FRAX® (Fracture Risk Assessment Tool), are also useful for clinical practice.7

    What do we do about it once we identify such patients?

    Recent guidelines recommend urgent initiation of treatment in all adults who have sustained a fragility fracture in the preceding 2 years to help prevent subsequent fractures.4-6 However, only about half of women aged ≥75 received therapy after an index fracture.3

  • About Expert

    Jonathan D. Adachi MD, FRCPC

    The Actavis Chair in Rheumatology for Better Bone Health Professor, Department of Medicine Michael G. DeGroote School of Medicine St. Joseph’s Healthcare – McMaster University Hamilton, Ontario.

    Dr. Jonathan Adachi is a Professor Emeritus of Medicine at the Michael G. DeGroote School of Medicine, McMaster University. Dr. Adachi has been involved in clinical trials and epidemiologic research. He either holds or is a co-investigator in several CIHR funded studies including the 20 year Canadian Multicentre Osteoporosis Study (CaMOS), and a separate study examining pQCT, HRpQCT and pMRI images of bone structure and strength to determine the relationship of bone structure and muscle to fractures in a subset of CaMOS subjects.

    Dr Adachi has over 600 peer reviewed publications and is a respected leader in bone research in Canada and Internationally. He was awarded the Lindy Fraser Award by Osteoporosis Canada. In 2006, he received the North American Menopause Society award for Innovation in Osteoporosis Research. In 2012, he received the Queen Elizabeth II Diamond Jubilee Medal for his work in osteoporosis and in 2014 he was received the Olof Johnell Science Award that honours an individual who has contributed to the field of osteoporosis in a scientific or policy implementation area worldwide. He was named the Consultant of the Year in 2016, awarded by Department of Family Medicine St Joseph’s Healthcare. In 2017 he was named the Inaugural Recipient of the  William G. Bensen Distinguished Faculty Award for career service to the Michael G. DeGroote School of Medicine and the Faculty of Health Sciences.  In 2019 he was awarded the Herbert Fleisch Medal by ESCEO-IOF in recognition of his outstanding and innovative contributions in basic or translational science.

  • References

    1. Ioannidis G, Papaioannou A, Hopman WM, et al. Relation between fractures and mortality: results from the Canadian Multicentre Osteoporosis Study. CMAJ. 2009;181(5):265-71.
    2. Balasubramanian A, Zhang J, Chen L, et al. Risk of subsequent fracture after prior fracture among older women. Osteoporos Int. 2019;30(1):79–92.
    3. Adachi J, Brown J, Schemitsch E, et al. Fragility fracture identifies patients at imminent risk for subsequent fracture: real-world retrospective database study in Ontario, Canada. BMC Musculoskeletal Disorders 2021;22:224-33.
    4. Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological Management of Osteoporosis in postmenopausal women: an Endocrine Society* clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1595–622.
    5. Kanis JA, Harvey NC, McCloskey E, Bruyere O, Veronese N, Lorentzon M, et al. Algorithm for the management of patients at low, high and very high risk of osteoporotic fractures. Osteoporos Int. 2020;31(1):1–12.
    6. Jin YZ, Lee JH, Xu B, Cho M. Effect of medications on prevention of secondary osteoporotic vertebral compression fracture, non-vertebral fracture, and discontinuation due to adverse events: a meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2019;20(1):399.
    7. Centre for Metabolic Bone Diseases. Fracture Risk Assessment Tool 2011. Available from: https://www.sheffield.ac.uk/FRAX/tool.aspx?country=19. Accessed 28 March 2022.

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