FRAX: re-adjust or re-think
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REVIEW
FRAX: re-adjust or re-think Yasser El Miedany 1 Received: 13 August 2020 / Accepted: 15 September 2020 # The Author(s) 2020
Abstract 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. Keywords Osteoporosis . FRAX . Fracture probability . Clinical risk factors . Intervention thresholds . Risk assessment . Screening . BMD . Adjustment . Artificial intelligence
Introduction The principle aim of osteoporosis treatment has been preventing or decreasing the risk of fragility fractures; therefore, a critical factor for patients’ management is the ability to assess fracture risk, identifying those eligible for intervention [1, 2]. The World Health Organization (WHO) Collaborating Centre at Sheffield, UK, released FRAX in 2008—a computer-based algorithm (http://www.shef.ac.uk/FRAX) that calculates individualised 10-year probability of hip and major osteoporotic fracture (clinical spine, distal forearm, and proximal humerus). As the probability of fractures differ considerably within and across different world regions [3, 4], FRAX models had to be calibrated to the fracture and death epidemiology in individual countries. At the time when FRAX was launched, models were only available for 8 nations. Currently, 71 models are available for 66 countries comprising more than 80% of the world population [5]. FRAX is available in 35 languages and approximately 3 million visits are received on the FRAX website annually. In 2018, the FRAX tool celebrated its 10th birthday [6].
* Yasser El Miedany [email protected] 1
King’s College London, London, England
FRAX tool is made up of seven dichotomous clinical risk factors which include prior fragility fracture, parental hip fracture, smoking, systemic glucocorticoid use, excess alcohol intake, rheumatoid arthritis, and other causes of secondary osteoporosis. In addition to age and sex and body mass index (BMI), these risk factors contribute to estimating a 10-year fracture probability, independent of bone mineral density (BMD). However, BMD at the femoral neck is an optional input variable [6, 7]. Earlier data had revealed that the sensitivity of BMD measurements for fracture prediction is low; t
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