國(guó)外骨折風(fēng)險(xiǎn)評(píng)估工具FRAX的應(yīng)用進(jìn)展

國(guó)外骨折風(fēng)險(xiǎn)評(píng)估工具FRAX的應(yīng)用進(jìn)展摘要：骨質(zhì)疏松性骨折是骨質(zhì)疏松最嚴(yán)重的后果，世界衛(wèi)生組織推薦使用簡(jiǎn)單易行的骨折風(fēng)險(xiǎn)預(yù)測(cè)工具FRAX評(píng)估患者的骨折風(fēng)險(xiǎn)，針對(duì)高風(fēng)險(xiǎn)人群進(jìn)行及時(shí)干預(yù)，大大降低其危害。國(guó)外有關(guān)FRAX應(yīng)用研究逐漸精細(xì)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(duì)FRAX預(yù)測(cè)結(jié)果影響的研究逐漸增多。本文就FRAX在國(guó)外類風(fēng)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(jìn)行綜述，F(xiàn)RAX在不同病種的應(yīng)用為臨床醫(yī)生及護(hù)士積極采取防治及護(hù)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(fēng)險(xiǎn)性；風(fēng)險(xiǎn)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(yán)重的后果，其具有高發(fā)病率、高死亡率的特點(diǎn)[[]CauleyJA,ChalhoubD,KassemAM,etal.Geographicandethnicdisparitiesinosteoporoticfractures.NatRevEndocrinol,2014,10(6),338-351.]，有研究預(yù)計(jì)到2025年歐洲人群之中每年發(fā)生OF的次數(shù)可達(dá)450萬(wàn)次[[]KanisJA,Borgstr?mF,CompstonJ,etal.SCOPE:ascorecardforosteoporosisinEurope.ArchOsteoporos,2013,8,144.]，由OF產(chǎn)生的直接費(fèi)用在美國(guó)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(jiǎn)介骨折風(fēng)險(xiǎn)評(píng)估工具(fractureriskassessmenttool，F(xiàn)RAX)是由英國(guó)Kanis教授等人在2008年研發(fā)的一種計(jì)算骨折風(fēng)險(xiǎn)的評(píng)估工具，該工具是根據(jù)骨折危險(xiǎn)因素和股骨頸骨密度（bonemineraldensity，BMD），通過一系列大樣本循證醫(yī)學(xué)原始數(shù)據(jù)計(jì)算建立，用來(lái)評(píng)價(jià)未來(lái)10年骨質(zhì)疏松性骨折風(fēng)險(xiǎn)的一個(gè)計(jì)算機(jī)評(píng)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(gè)骨折風(fēng)險(xiǎn)因子：既往低能量骨折史、雙親髖部骨折史、吸煙、長(zhǎng)期服用糖皮質(zhì)激素藥物、風(fēng)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(shí)可以在軟件中選擇輸入股骨頸BMD來(lái)提高其風(fēng)險(xiǎn)預(yù)測(cè)值。FRAX中骨折相關(guān)危險(xiǎn)因素是通過對(duì)北美、歐洲、亞洲、澳洲等多個(gè)獨(dú)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(jì)算模型中還需要相應(yīng)國(guó)家人群的骨折發(fā)生率和人群死亡率的流行病學(xué)資料，已知骨折發(fā)生率和人群死亡率流行病學(xué)資料的國(guó)家和地區(qū)已經(jīng)對(duì)FRAX進(jìn)行了校準(zhǔn)[[]KanisJA,JohnellO,DeLaetC,etal.Internationalvariationsinhipfractureprobabilities:implicationsforriskassessment.JBoneMinerRes,2002,17:1237-1244.]，WHO建議那些沒有本國(guó)資料的國(guó)家和地區(qū)可使用與自己國(guó)家最接近的計(jì)算工具，同樣具有良好參考價(jià)值。目前FRAX可應(yīng)用于31個(gè)國(guó)家和地區(qū)，并提供13種語(yǔ)言支持。美國(guó)指南中骨質(zhì)疏松性骨折高風(fēng)險(xiǎn)患者標(biāo)準(zhǔn):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(duì)這些高風(fēng)險(xiǎn)患者及時(shí)干預(yù)，而且FRAX可以不結(jié)合BMD進(jìn)行骨折風(fēng)險(xiǎn)評(píng)估，在一些骨密度檢測(cè)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,

FerreiraRJ,

SantosE,etal.Theaccuracyofosteoporoticfractureriskpredictiontools:asystematicreviewandmeta-analysis.\o"Annalsoftherheumaticdiseases."AnnRheumDis,2015,74(11):1958-1967.2在類風(fēng)濕關(guān)節(jié)炎患者中的應(yīng)用類風(fēng)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(guó)外學(xué)者Haugeberg等[[]HaugebergG,UhligT,FilchJA,etal.Bonemineraldensityandfrequencyofosteoporosisinfemalepatientswithrheumatoidarthritis:resultfrom394patientsintheOlsocountyrheumatoidarthritisregister.ArthritisRheum,2000,43(7):522-530.]報(bào)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(duì)324名非洲裔美國(guó)RA患者的研究發(fā)現(xiàn)，RA患者的骨折風(fēng)險(xiǎn)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(duì)其進(jìn)行有針對(duì)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(lái)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

density

in

women

withosteopenia

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

]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(fēng)險(xiǎn)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(duì)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(fēng)險(xiǎn)人群比例升高，分析原因可能為研究者們均無(wú)基于本國(guó)的FRAX模式，均使用基于意大利流行病學(xué)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

betweenFRAXscorescalculatedwithandwithout

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(zhǎng)期高血糖水平對(duì)骨骼的副作用應(yīng)視為糖尿病嚴(yán)重并發(fā)癥。傳統(tǒng)上僅認(rèn)為1型糖尿病可以增加骨折風(fēng)險(xiǎn)[[]DedeAD,

TournisS,

DontasI,etal.Type2

diabetesmellitus

andfracturerisk.\o"Metabolism:clinicalandexperimental."Metabolism,2014,63(12):1480-1490.]，隨著近年來(lái)2型糖尿病患病率增加，有關(guān)2型糖尿病與骨折風(fēng)險(xiǎn)關(guān)系的研究引起學(xué)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(duì)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(xué)者發(fā)現(xiàn)，2型糖尿病患者BMD較對(duì)照組低或者近似[[]YaturuS,HumphreyS,LandryC,etal.Decreasedbonemineraldensityinmenwithmetabolicsyndromealoneandwithtype2diabetes.MedSciMonit,2009,15(1):CR5-9.-[]McKennaMJ.Bone

mineral

density

in

non-insulin-dependentdiabetesmellitus.AnnInternMed,1995,123(9):731.

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

TournisS,

DontasI,etal.Type2

diabetesmellitus

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

density

in

non-insulin-dependent