FRAX and fracture prediction without bone mineral density.
The major application of FRAX in osteoporosis is to direct pharmacological interventions to those at high risk of fracture. Whereas the efficacy of osteoporosis treatment, with the possible exception of alendronate, is largely independent of baseline bone mineral density (BMD), it remains a widely held perception that osteoporosis therapies are only effective in the presence of low BMD. Thus, the use of FRAX in the absence of BMD to identify individuals requiring therapy remains the subject of some debate and is the focus of this review. The clinical risk factors used in FRAX have high evidence-based validity to identify a risk responsive to intervention. The selection of high-risk individuals with FRAX, without knowledge of BMD, preferentially selects for low BMD and thus identifies a risk that is responsive to pharmacological intervention. The prediction of fractures with the use of clinical risk factors alone in FRAX is comparable to the use of BMD alone to predict fractures and is suitable, therefore, in the many countries where facilities for BMD testing are sparse. In countries where access to BMD is greater, FRAX can be used without BMD in the majority of cases and BMD tests reserved for those close to a probability-based intervention threshold. Thus concerns surrounding the use of FRAX in clinical practice without information on BMD are largely misplaced.
a Centre for Metabolic Bone Diseases, University of Sheffield Medical School , UK ;
J A
JA
Kanis
b MRC Lifecourse Epidemiology Unit, University of Southampton , Southampton , UK ;
N C
NC
Harvey
a Centre for Metabolic Bone Diseases, University of Sheffield Medical School , UK ;|c Centre for Bone and Arthritis Research, Sahlgrenska Academy, University of Gothenburg , Gothenburg , Sweden ;
H
H
Johansson
a Centre for Metabolic Bone Diseases, University of Sheffield Medical School , UK ;
A
A
Odén
d University of Manitoba , Winnipeg , Canada.
W D
WD
Leslie
a Centre for Metabolic Bone Diseases, University of Sheffield Medical School , UK ;
E V
EV
McCloskey
D015502:Absorptiometry, Photon / Q000379:methods; D015519:Bone Density / Q000502:physiology; D050071:Bone Density Conservation Agents / Q000627:therapeutic use; D020000:Decision Support Systems, Clinical; D005260:Female; D050723:Fractures, Bone / Q000517:prevention & control*; D006801:Humans; D015663:Osteoporosis, Postmenopausal / Q000517:prevention & control*; D058866:Osteoporotic Fractures / Q000517:prevention & control*; D018570:Risk Assessment
D050071:Bone Density Conservation Agents
CLINICAL RISK FACTORS; FRACTURE PROBABILITY; FRAX; INTERVENTION THRESHOLDS; RISK ASSESSMENT