Is the Swedish FRAX model appropriate for Swedish immigrants?

[Osteoporosis-Definition, risk assessment, diagnosis, prevention and treatment (update 2024) : Guidelines of the Austrian Society for Bone and Mineral Research]

BACKGROUND

Austria is among the countries with the highest incidence and prevalence of osteoporotic fractures worldwide. Guidelines for the prevention and management of osteoporosis were first published in 2010 under the auspices of the then Federation of Austrian Social Security Institutions and updated in 2017. The present comprehensively updated guidelines of the Austrian Society for Bone and Mineral Research are aimed at physicians of all specialties as well as decision makers and institutions in the Austrian healthcare system. The aim of these guidelines is to strengthen and improve the quality of medical care of patients with osteoporosis and osteoporotic fractures in Austria.

METHODS

These evidence-based recommendations were compiled taking randomized controlled trials, systematic reviews and meta-analyses as well as European and international reference guidelines published before 1 June 2023 into consideration. The grading of recommendations used ("conditional" and "strong") are based on the strength of the evidence. The evidence levels used mutual conversions of SIGN (1++ to 3) to NOGG criteria (Ia to IV).

RESULTS

The guidelines include all aspects associated with osteoporosis and osteoporotic fractures, such as secondary causes, prevention, diagnosis, estimation of the 10-year fracture risk using FRAX®, determination of Austria-specific FRAX®-based intervention thresholds, drug-based and non-drug-based treatment options and treatment monitoring. Recommendations for the office-based setting and decision makers and institutions in the Austrian healthcare system consider structured care models and options for osteoporosis-specific screening.

CONCLUSION

The guidelines present comprehensive, evidence-based information and instructions for the treatment of osteoporosis. It is expected that the quality of medical care for patients with this clinical picture will be substantially improved at all levels of the Austrian healthcare system.

Race-specific FRAX models are evidence-based and support equitable care: a response to the ASBMR Task Force report on Clinical Algorithms for Fracture Risk

Task Force on 'Clinical Algorithms for Fracture Risk' commissioned by the American Society for Bone and Mineral Research (ASBMR) Professional Practice Committee has recommended that FRAX® models in the US do not include adjustment for race and ethnicity. This position paper finds that an agnostic model would unfairly discriminate against the Black, Asian and Hispanic communities and recommends the retention of ethnic and race-specific FRAX models for the US, preferably with updated data on fracture and death hazards. In contrast, the use of intervention thresholds based on a fixed bone mineral density unfairly discriminates against the Black, Asian and Hispanic communities in the US. This position of the Working Group on Epidemiology and Quality of Life of the International Osteoporosis Foundation (IOF) is endorsed both by the IOF and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO).

The hip fracture incidence in the high-risk area Oslo continues to decline

Oslo in Norway has had the highest incidence of hip fractures in the world. The incidence in Oslo has been thoroughly described every decade since the late 1970s. The incidence in Oslo has previously been higher compared to the rest of Norway but has now decreased to a level below the country average.

PURPOSE

The purpose of this study was to report the incidence of hip fractures in Oslo in 2019 and compare it with the incidence rates from the previous four decades.

METHODS

Patients residing in Oslo in 2019 with a new hip fracture identified by searching the Oslo hospital's patient administrative systems and protocols from the operating theaters. The diagnosis was verified through medical records and/or radiographs. To compare with previous studies, the direct standardization method was used with the population of Oslo in 2019 as the standard.

RESULTS

A total of 758 hip fractures, 70% women, were identified in 2019. The age-standardized incidence rates per 10,000 person-years in 2019 (95% CI) were 45 (41.1-48.8) for women and 30 (25.8-33.8) for men. In women, there has been a continuous decline in age-standardized rates the last three decades and in men the last two decades. The most pronounced decline was seen in the oldest age groups over 70 years. There has been a secular decline in both cervical and trochanteric fractures; however, the decrease in trochanteric fractures was most distinct for males, with more than two times higher risk in 1996/1997 compared to 2019.

CONCLUSION

Incidence rates for hip fractures in Oslo in 2019 were the lowest rate reported since 1978. The decrease was significant for both men and women. For the first time, the incidence rates are below the national rates of Norway. However, the rates are still among the highest worldwide.

Subsequent fracture risk in Norwegians and immigrants with an index forearm fracture: a cohort study

The current study investigated subsequent fracture risk following a forearm fracture in three country of birth categories: Norway, Europe and North America, and other countries. Subsequent fracture risk was modestly higher in Norwegian-born individuals compared to the two other groups. Secondary fracture prevention should be recommended regardless of country background.

BACKGROUND

Fracture risk is higher in patients with a previous fracture, but whether subsequent fracture risk differs by origin of birth is unknown. This study explores subsequent fracture risk in patients with an index forearm fracture according to region of birth.

METHODS

Nationwide data on forearm fractures in patients ≥ 18 years in 2008-2019 were obtained from the Norwegian Patient Registry and Statistics Norway. Index fractures were identified by ICD-10 code S52, whereas subsequent fractures included any ICD-10 fracture code. Data on country of birth were from Statistics Norway and included three regional categories: (1) Norway, (2) other Europe and North America and (3) other countries. Direct age standardization and Cox proportional hazard regression were used to analyse the data.

RESULTS

Among 143,476 individuals with an index forearm fracture, 35,361 sustained a subsequent fracture. Norwegian-born forearm fracture patients had the highest subsequent fracture rates (516/10,000 person-years in women and 380 in men). People born outside Europe and North America had the lowest rates (278/10,000 person-years in women and 286 in men). Compared to Norwegian-born individuals, the hazard ratios (HRs) of subsequent fracture in individuals from Europe and North American were 0.93 (95% CI 0.88-0.98) in women and 0.85 (95% CI 0.79-0.92) in men. The corresponding HRs in individuals from other countries were 0.76 (95% CI 0.70-0.84) in women and 0.82 (95% CI 0.74-0.92) in men.

CONCLUSION

Individuals born outside Norway had a lower subsequent fracture risk than Norwegian-born individuals; however, subsequent fracture risk increased with age in all groups. Our results indicate that secondary fracture prevention should be recommended regardless of region of origin.

An overview of the use of the fracture risk assessment tool (FRAX) in osteoporosis

FRAX®, a simple-to-use fracture risk calculator, was first released in 2008 and since then has been used increasingly worldwide. By calculating the 10-year probabilities of a major osteoporotic fracture and hip fracture, it assists clinicians when deciding whether further investigation, for example a bone mineral density measurement (BMD), and/or treatment is needed to prevent future fractures. In this review, we explore the literature around osteoporosis and how FRAX has changed its management. We present the characteristics of this tool and describe the use of thresholds (diagnostic and therapeutic). We also present arguments as to why screening with FRAX should be considered. FRAX has several limitations which are described in this review. This review coincides with the release of a version, FRAXplus, which addresses some of these limitations.

Osteoporosis and Fracture Risk among Older US Asian Adults

PURPOSE OF REVIEW

This review summarizes the current knowledge regarding osteoporosis and fracture among older US Asian adults.

RECENT FINDINGS

Asian adults have lower (areal) bone density than non-Hispanic White adults and thus are more likely to be diagnosed and treated for osteoporosis, despite their lower risk of hip fracture. The latter may relate to favorable characteristics in hip geometry, volumetric bone density, and bone microarchitecture; lower risk of falls; and other clinical factors. The fracture risk calculator FRAX accounts for the lower risk of hip fracture among US Asian adults. However, data on major osteoporotic fracture risk remain limited. Fracture rates also vary by Asian subgroup, which may have implications for fracture risk assessment. Furthermore, among women receiving bisphosphonate drugs, Asian race is a risk factor for atypical femur fracture, an uncommon complication associated with treatment duration. Recent clinical trial efficacy data pertaining to lower bisphosphonate doses and longer dosing intervals may be relevant for Asian adults. More research is needed to inform osteoporosis care of US Asian adults, including risk-benefit considerations and the optimal duration of bisphosphonate treatment. Greater evidence-based guidance for primary fracture prevention among US Asian adults will ensure health equity in the prevention of osteoporotic fractures.

Race/ethnic differences in the prevalence of osteoporosis, falls and fractures: a cross-sectional analysis of the Canadian Longitudinal Study on Aging

Most of the published epidemiology on osteoporosis is derived from White populations; still many countries have increasing ethno-culturally diverse populations, leading to gaps in the development of population-specific effective fracture prevention strategies. We describe differences in prevalent fracture and bone mineral density patterns in Canadians of different racial/ethnic backgrounds.

INTRODUCTION

We described prevalent fracture and bone mineral density (BMD) patterns in Canadians by their racial/ethnic backgrounds.

METHODS

For this cross-sectional analysis, we used the Canadian Longitudinal Study on Aging baseline data (2011-2015) of 22,091 randomly selected participants of Black, East Asian, South or Southeast Asian (SSEA) and White race/ethnic backgrounds, aged 45-85 years with available information on the presence or absence of self-reported prevalent low trauma fractures and femoral neck BMD (FNBMD) measurement. Logistic and linear regression models examined associations of race/ethnic background with fracture and FNBMD, respectively. Covariates included sex, age, height, body mass index (BMI), grip strength and physical performance score.

RESULTS

We identified 11,166 women and 10,925 men. Self-reported race/ethnic backgrounds were: 139 Black, 205 East Asian, 269 SSEA and 21,478 White. White participants were older (mean 62.5 years) than the other groups (60.5 years) and had a higher BMI (28.0 kg/m²) than both Asian groups, but lower than the Black group. The population-weighted prevalence of falls was 10.0%, and that of low trauma fracture was 12.0% ranging from 3.3% (Black) to 12.3% (White), with Black and SSEA Canadians having lower adjusted odds ratios (aOR) of low trauma fractures than White Canadians (Black, aOR = 0.3 [95% confidence interval: 0.1-0.7]; SSEA, aOR = 0.5 [0.3-0.8]). The mean (SD) FNBMD varied between groups: Black, 0.907 g/cm² (0.154); East Asian, 0.748 g/cm² (0.119); SSEA, 0.769 g/cm² (0.134); and White, 0.773 g/cm² (0.128). Adjusted linear regressions suggested that Black and both Asian groups had higher FNBMD compared to White.

CONCLUSION

Our results support the importance of characterizing bone health predictors in Canadians of different race/ethnic backgrounds to tailor the development of population-specific fracture prevention strategies.

Fracture risk in Asian-Canadian women is significantly over-estimated by the Canadian Association of Radiologists-Osteoporosis Canada risk prediction tool: retrospective cohort study

Fracture risk calculators may not be accurate for all ethnicity groups. The Manitoba bone density registry was used to test the Canadian CAROC tool for predicting fracture risk in Asian-Canadian women. The tool significantly over-estimated fracture risk, suggesting that it may not be ideal for Asian-Canadian patients.

PURPOSE

Health risk prediction tools based on largely White populations may lead to treatment inequity when applied to non-White populations where outcome rates differ. We examined the calibration of the Canadian Association of Radiologists-Osteoporosis Canada (CAROC) fracture risk prediction tool in self-identified Asian-Canadian women.

METHODS

Retrospective cohort study of women over age 50 using the Manitoba BMD Registry. At first BMD, the intake questionnaire collected self-identification of ethnicity and fracture risk factors. 10-year fracture risk was estimated using CAROC and categorized into low, medium, or high fracture risk. Linked administrative databases identified incident osteoporotic fractures. Observed fracture rates were compared between White and Asian-Canadians and compared to the original CAROC risk stratification.

RESULTS

There were 63,632 and 1703 women who self-identified as White-Canadian or Asian-Canadian, respectively, covering approximately 600,000 patient-years follow-up. There were 6588 incident fractures; a similar percentage of patients were assigned to each risk stratum at baseline by CAROC. A progressive rise in 10-year observed fracture rates occurred for each CAROC stratum in the White-Canadian population but much lower fracture rates than predicted in Asian-Canadian patients (p < 0.001). Fracture incidence rate ratios were 1.9-2.6 fold higher in White- vs Asian-Canadian patients for all strata (p < 0.001). In the CAROC moderate and high-risk categories, observed fracture rates in Asian-Canadian patients were typically lower than predicted, indicating poor model calibration.

CONCLUSION

In Asian-Canadian women, observed osteoporosis fracture rates are lower than predicted when using the CAROC tool. Over-estimation of fracture risk may influence shared decision-making discussions.

UK clinical guideline for the prevention and treatment of osteoporosis

The National Osteoporosis Guideline Group (NOGG) has revised the UK guideline for the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older. Accredited by NICE, this guideline is relevant for all healthcare professionals involved in osteoporosis management.

INTRODUCTION

The UK National Osteoporosis Guideline Group (NOGG) first produced a guideline on the prevention and treatment of osteoporosis in 2008, with updates in 2013 and 2017. This paper presents a major update of the guideline, the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older.

METHODS

Where available, systematic reviews, meta-analyses and randomised controlled trials were used to provide the evidence base. Conclusions and recommendations were systematically graded according to the strength of the available evidence.

RESULTS

Review of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment and intervention thresholds, management of vertebral fractures, non-pharmacological and pharmacological treatments, including duration and monitoring of anti-resorptive therapy, glucocorticoid-induced osteoporosis, and models of care for fracture prevention. Recommendations are made for training; service leads and commissioners of healthcare; and for review criteria for audit and quality improvement.

CONCLUSION

The guideline, which has received accreditation from the National Institute of Health and Care Excellence (NICE), provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals involved in its management. This position paper has been endorsed by the International Osteoporosis Foundation and by the European Society for the Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases.

Incidence of hip fracture in Saudi Arabia and the development of a FRAX model

A prospective hospital-based survey in representative regions of Saudi Arabia determined the incidence of fractures at the hip. The hip fracture rates were used to create a FRAX® model to facilitate fracture risk assessment in Saudi Arabia.

OBJECTIVE

This paper describes the incidence of hip fracture in the Kingdom of Saudi Arabia that was used to characterize the current and future burden of hip fracture, to develop a country-specific FRAX® tool for fracture prediction and to compare fracture probabilities with neighbouring countries.

METHODS

During a 2-year (2017/2018) prospective survey in 15 hospitals with a defined catchment population, hip fractures in Saudi citizens were prospectively identified from hospital registers. The number of hip fractures and future burden was determined from national demography. Age- and sex-specific incidence of hip fracture and national mortality rates were incorporated into a FRAX model for Saudi Arabia. Fracture probabilities were compared with those from Kuwait and Abu Dhabi.

RESULTS

The incidence of hip fracture applied nationally suggested that the estimated number of hip fractures nationwide in persons over the age of 50 years for 2015 was 2,949 and is predicted to increase nearly sevenfold to 20,328 in 2050. Hip fracture rates were comparable with estimates from Abu Dhabi and Kuwait. By contrast, probabilities of a major osteoporotic fracture or hip fracture from the age of 70 years were much lower than those seen in Abu Dhabi and Kuwait due to higher mortality estimates for Saudi Arabia.

CONCLUSION

A country-specific FRAX tool for fracture prediction has been developed for Saudi Arabia which is expected to help guide decisions about treatment.

Epidemiology of hip fracture in Qatar and development of a country specific FRAX model

Hip fracture data were retrieved from electronical medical records for the years 2017-2019 in the State of Qatar and used to create a FRAX® model to facilitate fracture risk assessment. Hip fracture rates were comparable with estimates from Saudi Arabia, Abu Dhabi, and Kuwait but fracture probabilities varied due to differences in mortality.

OBJECTIVE

This paper describes the epidemiology of osteoporotic fractures in the State of Qatar that was used to develop the country-specific fracture prediction FRAX® tool.

METHODS

Hip fracture data were retrieved from electronic medical records for the years 2017-2019 in the State of Qatar. The age and sex specific incidence of hip fracture in Qatari residents and national mortality rates were used to create a FRAX® model. Fracture probabilities were compared with those from neighboring countries having FRAX models.

RESULTS

Hip fracture rates were comparable with estimates from Saudi Arabia, Abu Dhabi and Kuwait. In contrast, probabilities of a major osteoporotic fracture or hip fracture were lower in Qatar than in Kuwait but higher than those in Abu Dhabi and Saudi Arabia due to differences in mortality.

CONCLUSION

The FRAX model should enhance accuracy of determining fracture probability among the Qatari population and help guide decisions about treatment.

Fracture risk assessment by the FRAX model

The introduction of the FRAX algorithms has facilitated the assessment of fracture risk on the basis of fracture probability. FRAX integrates the influence of several well-validated risk factors for fracture with or without the use of bone mineral density. Since age-specific rates of fracture and death differ across the world, FRAX models are calibrated with regard to the epidemiology of hip fracture (preferably from national sources) and mortality (usually United Nations sources). Models are currently available for 73 nations or territories covering more than 80% of the world population. FRAX has been incorporated into more than 80 guidelines worldwide, although the nature of this application has been heterogeneous. The limitations of FRAX have been extensively reviewed. Arithmetic procedures have been proposed in order to address some of these limitations, which can be applied to conventional FRAX estimates to accommodate knowledge of dose exposure to glucocorticoids, concurrent data on lumbar spine bone mineral density, information on trabecular bone score, hip axis length, falls history, type 2 diabetes, immigration status and recency of prior fracture.

Osteoporotic fractures in second-generation immigrants and Swedish natives

In this national study of osteoporotic fractures in second-generation immigrants in Sweden, we found a similar risk of osteoporotic fractures in general compared to Swedish natives, which suggests that environmental factors are important for the high risk of osteoporotic fractures in Nordic countries.

INTRODUCTION

Second generation immigrants may have a similar environment as individuals with two native-born parents. These individuals may be of interest to study concerning whether environmental or hereditary factors could be mostly associated to the risk of osteoporotic fractures. The aim of this study was to analyse the risk of osteoporotic fractures in second-generation immigrants compared to Swedish natives.

METHODS

This was a nationwide study of individuals aged 50 years of age and older (N = 1,377,035; 691,750 men and 685,285 women). Osteoporotic fractures were defined as at least one registered diagnosis of fractures in the hip, humerus, forearm or vertebrae, in the National Patient Register between January 1, 1998, and December 31, 2012. Cox regression analysis was used to estimate the relative risk (hazard ratios (HR) with 95% confidence intervals (CI)) of incident osteoporotic fractures in second generation immigrants compared to Swedish natives. The Cox regression models were adjusted for age, comorbidities and for sociodemographic status.

RESULTS

A total of 114,505 osteoporotic fractures were registered, 109,622 (8.4%) were among individuals with Swedish-born parents and 4883 (7.5%) among those with foreign-born parents, with distal forearm fractures dominating in general (44.9%). Fully adjusted HRs (95% CI) were for all immigrants 0.95 (95% CI, 0.91-0.99), for men 0.96 (95% CI, 0.89-1.04) and for women 0.95 (95% CI, 0.90-1.00).

CONCLUSIONS

We observed a similar risk of osteoporotic fractures among second-generation immigrants as in Swedish natives, which suggests that environmental factors are important for osteoporotic fractures.

Osteoporotic fractures among foreign-born individuals: a national Swedish study

In this national study of osteoporotic fractures in foreign-born individuals, we found a lower risk of osteoporotic fractures in general among foreign-born individuals compared with Swedish-born, especially in immigrants from southern Europe. A higher risk was found among some groups, i.e. men and women from Bosnia and Iraq and men from Lebanon.

INTRODUCTION

The aim of this study was to analyse risk of osteoporotic fractures in foreign-born individuals compared with Swedish-born individuals.

METHODS

This was a nationwide study of individuals 50 years of age and older (N = 2,775,736). Osteoporotic fractures were defined as at least one registered diagnosis of fractures in the hip, humerus, forearm or vertebrae, in the National Patient Register between January 1, 1998, and December 31, 2012. Cox regression analysis was used to estimate the relative risk (hazard ratios (HR) with 99% confidence intervals (CI)) of incident osteoporotic fractures in foreign-born compared with Swedish-born individuals. The Cox regression models were stratified by sex and adjusted for age, comorbidities and sociodemographic status.

RESULTS

A total of 362,899 osteoporotic fractures were registered (96,847 among men and 266,052 among women), with hip fractures dominating (54.0% among men, 42.6% among women). Fully adjusted HRs (99% CI) were for all immigrant men 0.75 (99% CI, 0.73-0.78) and women 0.83 (99% CI, 0.81-0.84), with significantly lower HRs among most groups but with higher HRs in certain countries. For the specific fractures, higher HRs were found for lower forearm fractures for men from Asia and for vertebral fractures among women from Asia.

CONCLUSIONS

We observed a generally lower risk of osteoporotic fractures among first-generation immigrants, with few exceptions.

Fracture prediction from FRAX for Canadian ethnic groups: a registry-based cohort study

We identified large between-ethnicity calibration differences in the Canadian FRAX® tool which substantially overestimated the major osteoporotic fracture (MOF) risk in Asian women and Black women, and overestimated hip fracture risk in Asian women.

PURPOSE

FRAX® is calibrated using population-specific fracture and mortality data. The need for FRAX to accommodate ethnic diversity within a country is uncertain. We addressed this question using the population-based Manitoba Bone Mineral Density (BMD) Program registry and self-reported ethnicity.

METHODS

The study population was women aged 40 years or older with baseline FRAX assessments (Canadian and other ethnic calculators), fracture outcomes, and self-reported ethnicity (White N = 68,907 [referent], Asian N = 1910, Black N = 356). Adjusted hazard ratios (HR) with 95% confidence intervals (CI) for time to MOF and hip fracture were estimated. We examined candidate variables from DXA that might contribute to ethnic differences including skeletal size, hip axis length (HAL), trabecular bone score (TBS), and estimated body composition.

RESULTS

Adjusted for baseline risk using the Canadian FRAX tool with BMD, Asian women compared with White women were at much lower risk for MOF (HR 0.46, 95% CI 0.35-0.59) and hip fracture (0.16, 95% CI 0.08-0.34). Black women were also at lower MOF risk (HR 0.58, 95% CI 0.32-1.00); there were no hip fractures. The US ethnic-specific FRAX calculators accounted for most of the between-ethnicity differences in MOF risk (86% for Asian, 92% for Black) but only partially accounted for lower hip fracture risk in Asian women (40%). The candidate variables explained only a minority of the effect of ethnicity. Gradient of risk in analyses was similar (p-interactions ethnicity*FRAX non-significant).

CONCLUSIONS

We identified significant ethnic differences in performance of the Canadian FRAX tool with fracture probability overestimated among Asian and Black women. The US ethnic calculators helped to address this discrepancy for MOF risk assessment, but not for hip fracture risk among Asian women.

Ethnic differences in risk of hip fracture in Norway: a NOREPOS study

Hip fracture is a major public health problem, and the incidence rates vary considerably between countries. Ethnic differences in bone mineral density have been identified as a factor to explain some of the geographical differences in rates of hip fracture. In this Norwegian register-based study, we found that all immigrant groups experienced lower risk of hip fracture than individuals born in Norway.

INTRODUCTION

Norway is among the countries with the highest incidence rates. The aim of this study was to investigate differences in risk of hip fracture between ethnic groups living in Norway.

METHODS

We linked individuals in the Norwegian Population and Housing Census conducted in 2001 and a database consisting of all hip fractures in Norway in the period 2001-2013. Residents (n = 1,392,949) between 50 and 89 years and born in nine different geographical regions of the world were examined, and we computed age-standardized incidence rates for the different geographic regions-denoted ethnic groups in the paper. Gender-stratified Cox regression analysis, adjusted for age, was used to model risk of hip fracture as a function of region of birth.

RESULTS

Age-standardized incidence rates of hip fracture varied considerably between regions of birth living in Norway, in both genders. All immigrant groups had lower risk of hip fracture compared to the Norwegian-born population. Immigrants from Central and Southeast Asia had the lowest risk of hip fracture when compared to individuals born in Norway (HR = 0.2, 95% CI 0.1-0.3 and HR =0.2, 95% CI 0.2-0.4 in men and women, respectively).

CONCLUSION

Lower risk of hip fracture was found in all immigrant groups compared to the Norwegian-born majority population.

A decade of FRAX: how has it changed the management of osteoporosis?

The fracture risk assessment tool, FRAX^®, was released in 2008 and provides country-specific algorithms for estimating individualized 10-year probability of hip and major osteoporotic fracture (hip, clinical spine, distal forearm, and proximal humerus). Since its release, 71 models have been made available for 66 countries covering more than 80% of the world population. The website receives approximately 3 million visits annually. Following independent validation, FRAX has been incorporated into more than 80 guidelines worldwide. The application of FRAX in assessment guidelines has been heterogeneous with the adoption of several different approaches in setting intervention thresholds. Whereas most guidelines adopt a case-finding strategy, the case for FRAX-based community screening in the elderly is increasing. The relationship between FRAX and efficacy of intervention has been explored and is expected to influence treatment guidelines in the future.

Algorithm for the management of patients at low, high and very high risk of osteoporotic fractures

Guidance is provided in an international setting on the assessment and specific treatment of postmenopausal women at low, high and very high risk of fragility fractures.

INTRODUCTION

The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2019. This manuscript seeks to apply this in an international setting, taking additional account of further categorisation of increased risk of fracture, which may inform choice of therapeutic approach.

METHODS

Clinical perspective and updated literature search.

RESULTS

The following areas are reviewed: categorisation of fracture risk and general pharmacological management of osteoporosis.

CONCLUSIONS

A platform is provided on which specific guidelines can be developed for national use to characterise fracture risk and direct interventions.

FRAX: re-adjust or re-think

Since its development in 2008, FRAX has booked its place in the standard day to day management of osteoporosis. The FRAX tool has been appreciated for its simplicity and applicability for use in primary care, but criticised for the same reason, as it does not take into account exposure response. To address some of these limitations, relatively simple arithmetic procedures have been proposed to be applied to the conventional FRAX estimates of hip and major fracture probabilities aiming at adjustment of the probability assessment. However, as the list of these adjustments got longer, this has reflected on its implementation in the standard practice and gave FRAX a patchy look. Consequently, raises the need to re-think of the current FRAX and whether a second generation of the tool is required to address the perceived limitations of the original FRAX. This article will discuss both point of views of re-adjustment and re-thinking.

European guidance for the diagnosis and management of osteoporosis in postmenopausal women

Guidance is provided in a European setting on the assessment and treatment of postmenopausal women at risk from fractures due to osteoporosis.

INTRODUCTION

The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2013. This manuscript updates these in a European setting.

METHODS

Systematic reviews were updated.

RESULTS

The following areas are reviewed: the role of bone mineral density measurement for the diagnosis of osteoporosis and assessment of fracture risk; general and pharmacological management of osteoporosis; monitoring of treatment; assessment of fracture risk; case-finding strategies; investigation of patients; health economics of treatment. The update includes new information on the evaluation of bone microstructure evaluation in facture risk assessment, the role of FRAX® and Fracture Liaison Services in secondary fracture prevention, long-term effects on fracture risk of dietary intakes, and increased fracture risk on stopping drug treatment.

CONCLUSIONS

A platform is provided on which specific guidelines can be developed for national use.

A brief history of FRAX

This paper reviews the research programme that went into the development of FRAX® and its impact in the 10 years since its release in 2008.

INTRODUCTION

Osteoporosis is defined on the measurement of bone mineral density though the clinical consequence is fracture. The sensitivity of bone mineral density measurements for fracture prediction is low, leading to the development of FRAX to better calculate the likelihood of fracture and target anti-osteoporosis treatments.

METHODS

The method used in this paper is literature review.

RESULTS

FRAX, developed over an 8-year period, was launched in 2008. Since the launch of FRAX, models have been made available for 64 countries and in 31 languages covering more than 80% of the world population.

CONCLUSION

FRAX provides an advance in fracture risk assessment and a reference technology platform for future improvements in performance characteristics.

FRAX Update

The fracture risk assessment tool, FRAX, was released in 2008 and provides country-specific algorithms for estimating individualized 10-year probability of hip and major osteoporotic fracture (hip, clinical spine, distal forearm, and proximal humerus). Since its release, models are now available for 63 countries, covering 79% of the world population. The website receives approximately 3 million visits annually. Following independent validation, FRAX has been incorporated into more than 80 guidelines worldwide. However, the application of FRAX in guidelines has been heterogeneous with the adoption of several different approaches to setting intervention thresholds. The relationship between FRAX and efficacy of intervention has been explored and is expected to influence treatment guidelines in the future. A more unified approach to setting intervention thresholds with FRAX is a research priority.

Worldwide Fracture Prediction

The substantial increase in the burden of non-communicable diseases in general and osteoporosis in particular, necessitates the establishment of efficient and targeted diagnosis and treatment strategies. This chapter reviews and compares different tools for osteoporosis screening and diagnosis; it also provides an overview of different treatment guidelines adopted by countries worldwide. While access to dual-energy X-ray absorptiometry to measure bone mineral density (BMD) is limited in most areas in the world, the introduction of risk calculators that combine risk factors, with or without BMD, have resulted in a paradigm shift in osteoporosis screening and management. To-date, forty eight risk assessment tools that allow risk stratification of patients are available, however only few are externally validated and tested in a population-based setting. These include Osteoporosis Self-Assessment Tool; Osteoporosis Risk Assessment Instrument; Simple Calculated Osteoporosis Risk Estimation; Canadian Association of Radiologists and Osteoporosis Canada calculator; Fracture Risk Assessment Calculator (FRAX); Garvan; and QFracture. These tools vary in the number of risk factors incorporated. We present a detailed analysis of the development, characteristics, validation, performance, advantages and limitations of these tools. The World Health Organization proposes a dual-energy X-ray absorptiometry-BMD T-score ≤ -2.5 as an operational diagnostic threshold for osteoporosis, and many countries have also adopted this cut-off as an intervention threshold in their treatment guidelines. With the introduction of the new fracture assessment calculators, many countries chose to include fracture risk as one of the major criteria to initiate osteoporosis treatment. Of the 52 national guidelines identified in 36 countries, 30 included FRAX derived risk in their intervention threshold and 22 were non-FRAX based.  No universal tool or guideline approach will address the needs of all countries worldwide.  Osteoporosis screening and management guidelines are best tailored according to the needs and resources of individual counties. While few countries have succeeded in generating valuable epidemiological data on osteoporotic fractures, to validate their risk calculators and base their guidelines, many have yet to find the resources to assess variations and secular trends in fractures, the performance of various calculators, and ultimately adopt the most convenient care pathway algorithms.

Epidemiology of fractures in Armenia: development of a country-specific FRAX model and comparison to its surrogate

Fracture probabilities derived from the surrogate FRAX model for Armenia were compared to those from the model based on regional estimates of the incidence of hip fracture. Disparities between the surrogate and authentic FRAX models indicate the importance of developing country-specific FRAX models. Despite large differences between models, differences in the rank order of fracture probabilities were minimal.

OBJECTIVE

Armenia has relied on a surrogate FRAX model based on the fracture epidemiology of Romania. This paper describes the epidemiology of fragility fractures in Armenia used to create an Armenia-specific FRAX model with an aim of comparing this new model with the surrogate model.

METHODS

We carried out a population-based study in two regions of Armenia (Ararat and Vayots Dzor representing approximately 11% of the country's population). We aimed to identify all low-energy fractures: retrospectively from hospital registers in 2011-2012 and prospectively in 2013 with the inclusion of primary care sources.

RESULTS

The differences in incidence between the surveys with and without data from primary care suggested that 44% of patients sustaining a hip fracture did not receive specialized medical care. A similar proportion of forearm and humeral fractures did not come to hospital attention (48 and 49%, respectively). Only 57.7% of patients sustaining a hip fracture were hospitalized. In 2013, hip fracture incidence at the age of 50 years or more was 201/100,000 for women and 136/100,000 for men, and age- and sex-specific rates were incorporated into the new "authentic" FRAX model for Armenia. Compared to the surrogate model, the authentic model gave lower 10-year fracture probabilities in men and women aged less than 70 years but substantially higher above this age. Notwithstanding, there were very close correlations in fracture probabilities between the surrogate and authentic models (> 0.99) so that the revisions had little impact on the rank order of risk.

CONCLUSION

A substantial proportion of major osteoporotic fractures in Armenia do not come to hospital attention. The disparities between surrogate and authentic FRAX models indicate the importance of developing country-specific FRAX models. Despite large differences between models, differences in the rank order of fracture probabilities were minimal.

Access to fracture risk assessment by FRAX and linked National Osteoporosis Guideline Group (NOGG) guidance in the UK-an analysis of anonymous website activity

In the UK, fracture risk guidance is provided by the National Osteoporosis Guideline Group (NOGG). NOGG usage showed widespread access through direct web-based linkage to FRAX. The facilitated interaction between fracture risk assessment and clinical guidelines could usefully be adopted in other countries.

INTRODUCTION

In the UK, guidance on assessment of osteoporosis and fracture risk is provided by the National Osteoporosis Guideline Group ( www.shef.ac.uk/NOGG ). We wished to determine access to this guidance by exploring website activity.

METHODS

We undertook an analysis of FRAX and NOGG website usage for the year between 1^st July 2013 and 30^th June 2014 using Google Analytics software.

RESULTS

During this period, there was a total of 1,774,812 sessions (a user interaction with the website) on the FRAX website with 348,964 of these from UK-based users; 253,530 sessions were recorded on the NOGG website. Of the latter, two-thirds were returning visitors, with the vast majority (208,766; 82 %) arising from sites within the UK. The remainder of sessions were from other countries demonstrating that some users of FRAX in other countries make use of the NOGG guidance. Of the UK-sourced sessions, the majority was from England, but the session rate (adjusted for population) was the highest for Scotland. Almost all (95.7 %) of the UK sessions arose from calculations being passed through from the FRAX tool ( www.shef.ac.uk/FRAX ) to the NOGG website, comprising FRAX calculations in patients without a bone mineral density (BMD) measurement (74.5 %) or FRAX calculations with a BMD result (21.2 %). National Health Service (NHS) sites were identified as the major source of visits to the NOGG website, comprising 79.9 % of the identifiable visiting locations, but this is an underestimate as many sites from within the NHS are not classified as such.

CONCLUSION

The study shows that the facilitated interaction between web-based fracture risk assessment and clinical guidelines is widely used in the UK. The approach could usefully be adopted in other countries for which a FRAX model is available.

A systematic review of intervention thresholds based on FRAX : A report prepared for the National Osteoporosis Guideline Group and the International Osteoporosis Foundation

This systematic review identified assessment guidelines for osteoporosis that incorporate FRAX. The rationale for intervention thresholds is given in a minority of papers. Intervention thresholds (fixed or age-dependent) need to be country-specific.

INTRODUCTION

In most assessment guidelines, treatment for osteoporosis is recommended in individuals with prior fragility fractures, especially fractures at spine and hip. However, for those without prior fractures, the intervention thresholds can be derived using different methods. The aim of this report was to undertake a systematic review of the available information on the use of FRAX® in assessment guidelines, in particular the setting of thresholds and their validation.

METHODS

We identified 120 guidelines or academic papers that incorporated FRAX of which 38 provided no clear statement on how the fracture probabilities derived are to be used in decision-making in clinical practice. The remainder recommended a fixed intervention threshold (n = 58), most commonly as a component of more complex guidance (e.g. bone mineral density (BMD) thresholds) or an age-dependent threshold (n = 22). Two guidelines have adopted both age-dependent and fixed thresholds.

RESULTS

Fixed probability thresholds have ranged from 4 to 20 % for a major fracture and 1.3-5 % for hip fracture. More than one half (39) of the 58 publications identified utilised a threshold probability of 20 % for a major osteoporotic fracture, many of which also mention a hip fracture probability of 3 % as an alternative intervention threshold. In nearly all instances, no rationale is provided other than that this was the threshold used by the National Osteoporosis Foundation of the USA. Where undertaken, fixed probability thresholds have been determined from tests of discrimination (Hong Kong), health economic assessment (USA, Switzerland), to match the prevalence of osteoporosis (China) or to align with pre-existing guidelines or reimbursement criteria (Japan, Poland). Age-dependent intervention thresholds, first developed by the National Osteoporosis Guideline Group (NOGG), are based on the rationale that if a woman with a prior fragility fracture is eligible for treatment, then, at any given age, a man or woman with the same fracture probability but in the absence of a previous fracture (i.e. at the 'fracture threshold') should also be eligible. Under current NOGG guidelines, based on age-dependent probability thresholds, inequalities in access to therapy arise especially at older ages (≥70 years) depending on the presence or absence of a prior fracture. An alternative threshold using a hybrid model reduces this disparity.

CONCLUSION

The use of FRAX (fixed or age-dependent thresholds) as the gateway to assessment identifies individuals at high risk more effectively than the use of BMD. However, the setting of intervention thresholds needs to be country-specific.

FRAX updates 2016

PURPOSE OF REVIEW

In the 8 years since the launch of the FRAX tool, it has continued to grow with the addition of new country or territory models. Although the core of the fracture risk algorithm remains unchanged, there is growing evidence of possible additional independent clinical variables that might modulate the interpretation of the FRAX outputs. There is also an expanding number of international guidelines that incorporate FRAX assessments, leading to discussions on the use of FRAX in treated patients and the determination of intervention thresholds.

RECENT FINDINGS

This review encompasses recent information on the use of FRAX in immigrant populations and the potential influence of skeletal and extraskeletal risk factors on FRAX estimations. For example, trabecular bone score and falls risk appear to be promising additional factors in individual risk assessment. FRAX appears to remain accurate in those on osteoporosis treatments, but FRAX is not a suitable tool for use in treat-to-target strategies.

SUMMARY

The assessment of fracture risk in immigrants is probably more accurate with the use of the FRAX tool for the country of origin, if available. The impact of additional risk variables will need evaluation of the impact of these on recharacterizing patients by moving them across intervention thresholds.

Osteoporosis: Modern Paradigms for Last Century's Bones

The skeleton is a metabolically active organ undergoing continuously remodelling. With ageing and menopause the balance shifts to increased resorption, leading to a reduction in bone mineral density and disruption of bone microarchitecture. Bone mass accretion and bone metabolism are influenced by systemic hormones as well as genetic and lifestyle factors. The classic paradigm has described osteoporosis as being a “brittle bone” disease that occurs in post-menopausal, thin, Caucasian women with low calcium intakes and/or vitamin D insufficiency. However, a study of black women in Africa demonstrated that higher proportions of body fat did not protect bone health. Isoflavone interventions in Asian postmenopausal women have produced inconsistent bone health benefits, due in part to population heterogeneity in enteric bacterial metabolism of daidzein. A comparison of women and men in several Asian countries identified significant differences between countries in the rate of bone health decline, and a high incidence rate of osteoporosis in both sexes. These studies have revealed significant differences in genetic phenotypes, debunking long-held beliefs and leading to new paradigms in study design. Current studies are now being specifically designed to assess genotype differences between Caucasian, Asian, African, and other phenotypes, and exploring alternative methodology to measure bone architecture.

Ethnic and geographic variations in the epidemiology of childhood fractures in the United Kingdom

BACKGROUND

Fractures are common in childhood, and there is considerable variation in the reported incidence across European countries, but few data relating to ethnic and geographic differences within a single country. We therefore aimed to determine the incidence of childhood fractures in the United Kingdom (UK), and to describe age-, ethnicity- and region- specific variations.

METHODS

The Clinical Practice Research Datalink (CPRD) contains anonymised electronic health records for approximately 7% of the UK population. The occurrence of a fracture between 1988 and 2012 was determined from the CPRD for all individuals <18years of age, and used to calculate fracture incidence rates for age, sex and ethnicity. Regional fracture incidence rates were also calculated based on general practitioner location within 14 Strategic Health Authorities (SHA) within the UK.

RESULTS

The overall fracture incidence rate was 137 per 10,000 person-years (py). This was higher in boys (169 per 10,000 py) than girls (103 per 10,000 py) and white children (150 per 10,000 py) compared to those of black (64 per 10,000 py) and South Asian (81 per 10,000 py) ethnicity. Marked geographic variation in incidence was observed. The highest fracture rates were observed in Wales, where boys and girls had 1.82 and 1.97 times greater incidence, respectively, than those residing in Greater London.

CONCLUSION

In the period 1988-2012, there was marked geographic and ethnic variation in childhood fracture incidence across the UK. These findings also implicate lifestyle and socio-economic differences associated with location and ethnicity, and are relevant to policy makers in the UK and internationally.