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Do you think FRAX is a beneficial tool in the identification of the risk for osteoporosis?
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FRAX remains limited
Yes, it is a beneficial tool because the old-fashioned way of talking about risk was to say that someone had two-times the risk or 1.5-times the risk of the general population for something untoward to happen. Luckily, most bad things in life are rare events, so this type of statistic did not sound particularly worrisome and the intended warnings just did not resonate with people. The beauty of FRAX is that it is person-specific. It tells the patient what their personal risk of both hip and non-hip fracture is during the next 10 years.
I have had the opportunity to speak with numerous women groups about bone health during the years. Moments after I discuss FRAX, all the cellphones come out and women in the audience start busily calculating their FRAX score because they want to understand their specific risk score. Discussing FRAX scores helps take bone health from the abstract to the person. In brief, I think the FRAX is brilliant.
On the other hand, as a predictive tool, it is important to understand FRAX remains limited. The developers of FRAX wanted to devise a tool that could be used internationally. Unfortunately, the epidemiologic data was limited in some regions, and there was only DXA data available for the United States. The list of variables included in FRAX is also limited, and items, such as physical activity, vitamin D level and history of other fractures, are not included. FRAX is an imperfect tool, but I would argue it is the best thing we have. I believe it will be updated and refined over the years.
One of the other important things the FRAX team did is look at race/ethnicity, which turns out to be important predictors of bone health. The U.S. version of the FRAX allows an individual to calculate fracture risk using their DXA result and race. While DXA scans are widely available in the United States, these are not widely available in most other countries.
In summary, FRAX is a wonderful tool. I think it will be updated and expanded, but for right now, it is the best tool we have to help patients focus on why they need to pay attention to their bone health.
Laura L. Tosi, MD, is the director of the Bone Health Clinic at Children’s National Health System, Washington.
Disclosure: Tosi reports no relevant financial disclosures.
Provides treatment recommendation
During the last 2 decades, bone health has assumed a more prominent position in the lexicon of patients’ medical conditions, especially the recognition and treatment of osteoporosis. This has occurred as a result of the numerous pharmacologic agents available to improve bone mass and skeletal health. With 10 million or more individuals in the United States afflicted with osteoporosis and more than 50 million living with low bone mass, this speaks to a major public health problem, and one that will become even more prominent in the future with our aging population.
Orthopedic surgeons have become more aware of this concern as it applies most significantly to patients who have already sustained a fragility fracture and need secondary fracture prevention. This is due to the well-documented fact that a current fracture is the greatest harbinger of future fractures. While many agents are available for treatment, there is still a major treatment gap between those who need treatment for osteoporosis and those who actually receive or maintain the treatment prescribed. This has caused many physicians to avoid prescribing pharmacologic treatment because of their patients’ fears of rare side effects and their own concerns about whom to treat and what agent to use. Because many patients with low bone mass alone and not true osteoporosis were treated for extended periods of time with bisphosphonates, which in some cases resulted in rare, adverse events. Due to this, the international medical community was spurred to develop a clinical risk assessment tool to determine which patients actually needed treatment. Thus, FRAX was developed by John A. Kanis of the University of Sheffield, United Kingdom, and popularized by the WHO in 2008.
FRAX was originally intended as a means to determine which patients who were without fracture and with low bone mass (not true osteoporosis by DXA) needed treatment. It can be applied in secondary fracture prevention for those patients in the early part of the older adult spectrum who may have sustained fragility fractures of the distal radius, proximal humerus, vertebrae or other than hip fractures, especially if they had DXA testing in the osteopenic range and are reluctant to use osteoporosis medications.
FRAX scores estimate fracture risk to be significant and consistent with the need for osteoporosis treatment if a patient’s 10-year risk of hip fracture is equal to or greater than 3%, and the risk of other major osteoporotic fracture is equal to or greater than 20%. Elements analyzed in the scoring system include patient demographic data, weight, height and medical history, including previous fracture, history of hip fracture in a parent, glucocorticoid therapy, rheumatoid arthritis, secondary osteoporosis, smoking and alcohol consumption (hip DXA score optional). This functional tool can be easily accessed online by simply entering FRAX or through a smartphone FRAX application. Due to population differences, it is country-specific and has been validated for 58 countries and is available in 32 languages. While some individuals may feel the probability ranges are too narrow, FRAX provides some statistical evidence to support a recommendation for osteoporosis treatment in fragility fracture patients with osteopenia (DXA = -1.0 > -2.5). According to a well-recognized position statement from the National Bone Health Alliance (NBHA) Working Group, while patients with hip fractures are now considered to have osteoporosis by definition with or without DXA testing, FRAX is useful in orthopedic patients with other fragility fractures.
When taken into account with patient personal factors, an elevated FRAX score (keeping with another recommendation of the NBHA) clearly supports an orthopedic surgery — or other health care provider — pharmacologic treatment recommendation for bone health improvement in older adult patients with fragility fractures of the vertebrae, proximal humerus, pelvis or distal forearm to prevent their future fractures.
Andrew D. Bunta, MD, is an associate professor in the Department of Orthopedic Surgery at the Northwestern University Feinberg School of Medicine, Chicago.
Disclosure: Bunta reports no relevant financial disclosures.