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FRAX: A way toward better bone health
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Historically, orthopedic surgeons have treated patients with fractures; but when it comes to addressing the prevention and treatment of osteoporosis, patients are recommended to their primary care physician or other medical professional.
“Some orthopedists feel like our role is to take care of fracture, but not necessarily osteoporosis,” Kyle J. Jeray, MD, vice chair of academics at the Greenville Health System at the University of South Carolina and chair of the Own the Bone steering committee for the American Orthopaedic Association, told Orthopedics Today. “Oftentimes poor bone quality goes hand-in-hand with fractures, and if we see a patient who has a fracture and ends up having poor bone quality, they are certainly at high risk for having another fracture.”
According to Jeray, the first fracture in a patient older than 40 years to 50 years old is known as the centennial event in orthopedics and should be a cue for orthopedists to evaluate the patient’s bone health, which can be done through the Fracture Risk Assessment Tool (FRAX).
Image: Tanner S
FRAX was developed by a WHO task force in 2008 and is based off of data collected during a 10-year period. FRAX was established to help clinicians better understand which of their patients are at a higher risk for osteoporosis-associated fractures, according to Ethel S. Siris, MD, professor of medicine and director of the Toni Stabile Osteoporosis Center at Columbia University Medical Center.
“[FRAX] was an attempt to recognize bone density testing as a useful tool for looking at which older patients might be at a high risk for fractures, but it is not the necessarily the sole story,” Siris said.
FRAX uses a combination of bone density testing from a bone densitometry (DXA) scanner and other clinical factors to help diagnose the risk of osteoporosis in patients older than 40 years of age.
“FRAX is an algorithm that takes into account some of those other risk factors that go with the diagnosis of the disease of osteoporosis,” Susan V. Bukata, MD, vice chairman and associate professor of orthopedics at UCLA, told Orthopedics Today. “While we know the bone density score is important, the problem is we realize the combination of density plus some quality factors, [which] compromise the strength of the bone, give [patients] the disease of osteoporosis.”
Some risk factors included in FRAX are age, gender, weight, height, previous fracture, family history of hip fracture, smoking status, use of glucocorticoids, rheumatoid arthritis, alcohol intake and bone mineral density measured by a DXA scan, according to Jeray.
“[FRAX] will give you the 10-year probability of having a hip fracture, and it will give you a 10-year probability of having what they consider a major osteoporotic fracture, which is a wrist fracture, a proximal humerus fracture or spine fracture,” Jeray said.
Abraham G. Lin, MD, assistant chief of the orthopedics at Kaiser Permanente Downey, noted there are separate FRAX models available depending on the patient’s ethnicity. Different ethnicities have different rates of fracture, and the accuracy of the FRAX model is improved with inclusion of country, age and sex specific rates of other major osteoporotic fractures.
“Fairer-skinned patients are at higher risk for having poor bone quality than darker-skinned patients, and it varies from geography to geography,” Jeray said.
According to the National Osteoporosis Foundation, patients should undergo initial evaluation and treatment for osteoporosis, if FRAX shows they have a 3% or higher risk for the probability of having a hip fracture in the next 10 years or if they have a 10-year probability for a major osteoporotic fracture of 20%. However, Siris noted physicians can still treat patients, if they do not fall inside the threshold.
“[The National Osteoporosis Foundation] does not say you cannot treat if it is less than [20%],” Siris said. “If you have somebody with an 18% risk of major osteoporotic fracture [and] not 20%, and you want to treat the patient medically, [then] go for it. You and the patient may make that decision.”
Benefits, drawbacks
Douglas P. Kiel, MD, director of the Musculoskeletal Research Center at the Institute for Aging Research, part of Hebrew SeniorLife and professor of medicine at Harvard Medical School, said FRAX also can be performed without a DXA scan, which is beneficial in countries that do not have access to bone density machines.
“The advantages of FRAX is there is one version of it where you do not need a bone density test,” Kiel said. “You can ask medical questions about [a patient’s] history and calculate a score. Around the world, this version is used as the first cut because you do not have to send [the patient] out of the office.”
Bukata noted FRAX can help physicians emphasize patients’ increased risk of fracture.
“We live in a society where people do not want to admit they are aging or they are older,” Bukata said “I regularly see patients in their late 70s and early 80s who have aged well, are healthy, are active and are vigorous, and it is a way to show them they are at an increased risk of this silent disease and should be on medications, [which] have proven to be effective in preventing that first fracture even though they feel fine.”
However, Jeray noted the questions on FRAX can only be answered in a “yes/no” fashion, which means FRAX does not take into account the specific number of fractures or other clinical risk factors patients have that may affect their risk of osteoporosis.
“For our patients who are 40 [years] and older who may have had multiple fractures, FRAX asks simple yes or no [questions],” Jeray said. “For example, if you have had three or more fractures, you are at a higher risk than the patient who has had one fracture. That is where FRAX is not good at capturing the risk factor.”
According to Lin, FRAX does not take into account patients who fall frequently, patients on high doses of inhaled glucocorticoids and patients who are taking at least 5 mg of prednisone daily or for 3 months or longer — all of which can lead to a higher risk of fracture.
“However, FRAX does consider patients who are on prednisone less than 3 months and are taking a dose less than 5 mg daily,” Lin said.
Siris said physicians should “inflate” the number they receive from the FRAX calculation if patients clearly have risk factors for osteoporosis not taken into account by FRAX.
With the increase in life expectancy, the data included in FRAX is not always up to date, according to Jeray.
“They do continue to change their actuarial tables that give these probabilities, but sometimes that can throw off the information you get from FRAX, which makes it not as accurate as you would like,” Jeray said.
The bone density scan is based off the femoral neck, which can cause issues among patients with low scores in their spine, Bukata said.
“It is imperfect in that it is based off the score at the femoral neck on the bone density scan, so it is possible for someone to have disproportionately low scores in their spine and have it not be reflected in their FRAX score,” she said. “But it is a good way for us to estimate when people are crossing that threshold of risk, so we can provide more cost-effective and more risk benefit-balanced preventative medications and care.”
Other tools
Besides FRAX, there are several other risk calculators for osteoporosis and fractures. Named after the Garvan Institute in Australia, Kiel noted the GARVAN Risk Calculator is slightly different from FRAX because it includes fewer risk factors. However, it includes history of falls, which is not included in the FRAX.
“Most orthopedic surgeons realize that, other than being in a motor vehicle accident or having a high traumatic incident, most of the fractures occur with a fall, [which] is why falls are included in the GARVAN Risk Calculator,” Kiel said.
The Male Osteoporosis Risk Estimation score (MORES) is another risk calculator, but is used to identify which men need screening for osteoporosis compared with which men have osteoporosis, according to Lin.
“FRAX and MORES are not comparable to each other,” Lin said. “FRAX is used to determine if treatment is indicated, and MORES is used to identify which men need screening for osteoporosis.”
Jeray noted the Foundation for Osteoporosis Research and Education (FORE) has a similar tool that adds to the areas that FRAX has been criticized for, such as the specific amount of steroids a patient is prescribed and bone density measurements in the spine rather than the hip.
“With FRAX, you use bone density at the hip, specifically the femoral neck, and FRAX has been criticized in populations where spine fractures are more common. FORE takes that into account as well,” Jeray said.
According to Siris, despite the other tools available, FRAX is more detailed and based on a higher number of individuals and takes into account each country’s fracture and death rates.
“[FRAX] is unique and the first step forward in the world of osteoporosis,” she said. “In the past we have relied upon the bone density score and a general gestalt about the patient. This is a way for us to — based on databases, based on ethnic and racial databases — get a better sense of what that person’s risk is. Not perfect, but it is much better than what we were doing.”
Siris added, “In the United States, it is believed that FRAX is not needed if the T-score from a DXA test clearly shows osteoporosis, but it is useful in patients whose T-scores convey osteopenia, as some of these patients may be at high risk for fracture once FRAX is applied.”
FRAX administration
When it comes to administering FRAX, most orthopedic surgeons may not be the ones administering it. Siris noted they are not obligated to, but may wish to. However, Bukata said orthopedists can utilize FRAX when they see a patient who has a smaller fracture as a way to estimate the overall fracture risk.
“Orthopedic surgeons can use [FRAX] effectively if the patient has a smaller fracture, an ankle fracture, a wrist fracture, a proximal humerus fracture — things that we think probably show that they have osteoporosis. It is a way for use to estimate their overall fracture risk and whether they should go on to medication for osteoporosis,” she said.
According to Siris, when an orthopedist is seeing a post-menopausal woman or man older than 50 years of age who has already experienced a fracture, they should not administer FRAX, but perform an osteoporosis work-up.
“The most important message for orthopedic surgeons is if somebody in these age categories comes in with a low-energy fracture, you do not need to [perform] FRAX,” Siris said. “You need to do an osteoporosis work-up, bone density [testing] and certain typical blood tests, and then assure calcium and D sufficiency, treat the patient with a drug or refer the patient for assessment to the internist, the endocrinologist, who is an expert on bone, or the rheumatologist, if that is your local expert.”
Fracture prevention
Since orthopedic surgeons do not generally see patients until after the fracture has occurred, one of the primary focuses should be the prevention of future fractures. However, many orthopedic surgeons believe it is not their area to ensure patients undergo preventative measures for future fractures, according to Kiel. To reduce incidence of future fractures, which can positively impact osteoporosis treatment, the American Orthopaedic Association established the Own the Bone program.
“[Own the Bone] is an attempt not to refer it back to primary care, but take ownership of this unique window of opportunity to get people treated,” Kiel said.
Jeray said that if orthopedic surgeons do not want to treat patients for osteoporosis and future fractures, they should be sure to send [patients] to their primary care physician or other medical professional who are willing to assume care for their bone health.
Orthopedic surgeons interested in treating patients for osteoporosis can help establish a Fracture Liaison Service with other medical professionals in their hospital or health care system.
“Fracture Liaison Services have been shown in the medical literature to be the best way to get the post-fracture patient subsequently worked up for secondary prevention of more fractures,” Siris said.
A Fracture Liaison Service program is led by a liaison person who navigates patients from the “orthopedic component of the fracture management subsequently to a medical component for work-up and treatment to prevent the next fracture. [The liaison person can] be an orthopedic surgeon, nurse, non-physician clinical coordinator, internist, etc.,” Siris said.
“A majority of [orthopedic surgeons] have a program in cooperation with what they call ‘osteoporosis champions’ at their institution or within their network who [are not orthopedic surgeons and] are happy to see these patients for the medical management,” she said.
Another way orthopedic surgeons can help treat osteoporosis and prevent future fractures in patients is by speaking with younger patients about overall bone health if they recognize risk factors associated with a higher risk of fracture while treating the patient for another problem, such as total joint replacement, according to Bukata.
“In recognizing younger patients who might have risk factors, [such as patients diagnosed with] autoimmune disease, [those who] are on steroids, [those who]have had transplants, [those who] have had chemotherapy, [those who] have had eating disorders [and those who] have other diseases that put their bones at risk, having a 30-second conversation with them about their overall bone health would make a huge difference in helping to prevent fracture and getting them referred for testing and evaluation, if necessary,” Bukata said.
“However you do it, it is important that you recognize the problem and talk to the patient, and as I said you can make a difference in recurrent fractures, which I think is important,” Jeray said. – by Casey Tingle
- References:
- Fracture Risk Assessment Tool (FRAX). Available at: www.rheumatology.org/I-Am-A/Rheumatologist/Research/Clinician-Researchers/Fracture-Risk-Assessment-Tool-FRAX. Accessed Oct. 27, 2016.
- What is Own the Bone? Available at: www.ownthebone.org/OTB/About/What_Is_Own_the_Bone/OTB/About/What_Is_Own_the_Bone.aspx?hkey=fc52b39e-83ae-440f-b209-a1204c7302c7. Accessed Sept. 30, 2016.
- For more information:
- Susan V. Bukata, MD, can be reached at 1250 16th St., Suite 1200, Santa Monica, CA 90404; email: sbukata@mednet.ucla.edu.
- Kyle J. Jeray, MD, can be reached at Greenville Health System Orthopedics, 105 Doctors Dr., Greenville, SC 29605; email: kjeray@ghs.org.
- Douglas P. Kiel, MD, MPH, can be reached at the Institute for Aging Research, 1200 Centre St., Boston, MA 02131; email: kiel@hsl.harvard.edu.
- Abraham G. Lin, MD, can be reached at Kaiser Permanente, 9353 Imperial Hwy., Downey, CA 90242; email: vincent.p.staupe@kp.org.
- Ethel S. Siris, MD, can be reached at Columbia University Medical Center, 622 W. 168th St., New York, NY 10032; email: es27@cumc.columbia.edu.
Disclosures: Bukata reports she is a consultant for Merck, Amgen and Eli Lilly; is on the speakers bureau for Eli Lilly; and is on the board of the National Osteoporosis Foundation. Jeray reports he is the chair for the Own the Bone steering committee. Kiel reports he receives royalties from Springer and Wolters Kluwer and serves as a scientific advisor for Merck Sharp & Dohme; and his institution has a grant from Merck Sharp & Dohme. Lin and Siris report no relevant financial disclosures.
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, “Do you think FRAX is a beneficial tool in the identification of the risk for osteoporosis?”