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From relative risk to absolute fracture risk calculation: The FRAX algorithm

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Abstract

FRAX is a computer-based algorithm that provides models for the assessment of fracture probability in men and women (http://www.shef.ac.uk/FRAX). The approach uses easily obtained clinical risk factors to estimate 10-year fracture probability, with or without femoral neck bone mineral density (BMD), to enhance fracture risk prediction. It has been constructed using primary data from population-based cohorts around the world. The gradients of fracture risk have been validated in independent cohorts with a similar geographic distribution. The FRAX tool should not be considered as a gold standard, but rather as a platform technology on which to build as new validated risk indicators become available. Notwithstanding, the present models provide an aid to enhance patient assessment by the integration of clinical risk factors alone and/or in combination with BMD. This article describes the steps undertaken in the development of FRAX.

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References and Recommended Reading

  1. World Health Organization: Assessment of Fracture Risk and its Application to Screening for Postmenopausal Osteoporosis; Technical Report No. 843. Geneva, Switzerland: World Health Organization; 1994.

    Google Scholar 

  2. World Health Organization: The World Health Report, 1997: Conquering Suffering, Enriching Humanity. Geneva, Switzerland: World Health Organization; 1997.

    Google Scholar 

  3. Genant HK, Cooper C, Poor G, et al.: Interim report and recommendations of the World Health Organization Task-Force for Osteoporosis. Osteoporos Int 1999, 10:259–264.

    Article  PubMed  CAS  Google Scholar 

  4. Kanis JA, McCloskey EV, Johansson H, et al.: A reference standard for the description of osteoporosis. Bone 2008, 42:467–475.

    Article  PubMed  CAS  Google Scholar 

  5. Kanis JA, Johnell O, De Laet C, et al.: A meta-analysis of previous fracture and subsequent fracture risk. Bone 2004, 35:375–382.

    Article  PubMed  CAS  Google Scholar 

  6. Kanis JA, Johansson H, Oden A, et al.: A family history of fracture and fracture risk: a meta-analysis. Bone 2004, 35:1029–1037.

    Article  PubMed  CAS  Google Scholar 

  7. Feskanich D, Willett W, Colditz G: Walking and leisure-time activity and risk of hip fracture in postmenopausal women. JAMA 2002, 288:2300–2306.

    Article  PubMed  Google Scholar 

  8. Kanis JA, Johnell O, Oden A, et al.: Smoking and fracture risk: a meta-analysis. Osteoporos Int 2005, 16:155–162.

    Article  PubMed  CAS  Google Scholar 

  9. World Health Organization: WHO Scientific Group on the Assessment of Osteoporosis at the Primary Health Care Level, Summary Meeting Report, Brussels, Belgium, 5–7 May 2004. Geneva, Switzerland: World Health Organization; 2007.

    Google Scholar 

  10. O’Neill TW, Felsenberg D, Varlow J, et al.: The prevalence of vertebral deformity in European men and women: the European Vertebral Osteoporosis Study. J Bone Miner Res 1996, 11:1010–1018.

    Article  PubMed  Google Scholar 

  11. Jones G, Nguyen T, Sambrook PN, et al.: Symptomatic fracture incidence in elderly men and women: the Dubbo Osteoporosis Epidemiology Study (DOES). Osteoporos Int 1994, 4:277–282.

    Article  PubMed  CAS  Google Scholar 

  12. Jackson SA, Tenenhouse A, Robertson L: Vertebral fracture definition from population-based data: preliminary results from the Canadian Multicenter Osteoporosis Study (CaMos). Osteoporos Int 2000, 11:680–687.

    Article  PubMed  CAS  Google Scholar 

  13. Melton LJ 3rd: History of the Rochester Epidemiology Project. Mayo Clin Proc 1996, 71:266–274.

    Article  PubMed  Google Scholar 

  14. Melton LJ 3rd: The prevalence of osteoporosis: gender and racial comparison. Calcif Tissue Int 2001, 69:179–181.

    Article  PubMed  CAS  Google Scholar 

  15. McCloskey EV, Beneton M, Charlesworth D, et al.: Clodronate reduces the incidence of fractures in community-dwelling elderly women unselected for osteoporosis: results of a double-blind, placebo-controlled randomized study. J Bone Miner Res 2007, 22:135–141.

    Article  PubMed  CAS  Google Scholar 

  16. Van der Klift M, De Laet CE, McCloskey EV, et al.: The incidence of vertebral fractures in men and women: the Rotterdam Study. J Bone Miner Res 2002, 17:1051–1056.

    Article  PubMed  Google Scholar 

  17. van der Klift M, de Laet CE, McCloskey EV, et al.: Risk factors for incident vertebral fractures in men and women: the Rotterdam Study. J Bone Miner Res 2004, 19:1172–1180.

    Article  PubMed  Google Scholar 

  18. Honkanen RJ, Honkanen K, Kroger H, et al.: Risk factors for perimenopausal distal forearm fracture. Osteoporos Int 2000, 11:265–270.

    Article  PubMed  CAS  Google Scholar 

  19. Fujiwara S, Kasagi F, Yamada M, Kodama K: Risk factors for hip fracture in a Japanese cohort. J Bone Miner Res 1997, 12:998–1004.

    Article  PubMed  CAS  Google Scholar 

  20. Albrand G, Munoz F, Sornay-Rendu E, et al.: Independent predictors of all osteoporosis-related fractures in healthy postmenopausal women: the OFELY study. Bone 2003, 32:78–85.

    Article  PubMed  CAS  Google Scholar 

  21. Dargent-Molina P, Douchin MN, Cormier C, et al.: Use of clinical risk factors in elderly women with low bone mineral density to identify women at higher risk of hip fracture: The EPIDOS prospective study. Osteoporos Int 2002, 13:593–599.

    Article  PubMed  CAS  Google Scholar 

  22. Svanborg A: Seventy-year-old people in Gothenburg a population study in an industrialized Swedish city. II. General presentation of social and medical conditions. Acta Med Scand Suppl 1977, 611:5–37.

    PubMed  CAS  Google Scholar 

  23. Kanis JA, Johansson H, Oden A, et al.: A meta-analysis of prior corticosteroid use and fracture risk. J Bone Miner Res 2004, 19:893–899.

    Article  PubMed  Google Scholar 

  24. De Laet C, Oden A, Johansson H, et al.: The impact of the use of multiple risk indicators for fracture on case-finding strategies: a mathematical approach. Osteoporos Int 2005, 16:313–318.

    Article  PubMed  Google Scholar 

  25. Kanis JA, Oden A, Johnell O, et al.: The use of clinical risk factors enhances the performance of BMD in the prediction of hip and osteoporotic fractures in men and women. Osteoporos Int 2007, 18:1033–1046.

    Article  PubMed  CAS  Google Scholar 

  26. Looker AC, Wahner HW, Dunn WL, et al.: Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 1998, 8:468–489.

    Article  PubMed  CAS  Google Scholar 

  27. Marshall D, Johnell O, Wedel H: Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ 1996, 312:1254–1259.

    PubMed  CAS  Google Scholar 

  28. Schott AM, Cormier C, Hans D, et al.: How hip and whole-body bone mineral density predict hip fracture in elderly women: the EPIDOS Prospective Study. Osteoporos Int 1998, 8:247–254.

    Article  PubMed  CAS  Google Scholar 

  29. Cummings SR, Nevitt MC, Browner WS, et al.: Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med 1995, 332:767–773.

    Article  PubMed  CAS  Google Scholar 

  30. Sanders KM, Nicholson GC, Ugoni AM, et al.: Health burden of hip and other fractures in Australia beyond 2000. Projections based on the Geelong Osteoporosis Study. Med J Aust 1999, 170:467–470.

    PubMed  CAS  Google Scholar 

  31. Sanders KM, Pasco JA, Ugoni AM, et al.: The exclusion of high trauma fractures may underestimate the prevalence of bone fragility fractures in the community: the Geelong Osteoporosis Study. J Bone Miner Res 1998, 13:1337–1342.

    Article  PubMed  CAS  Google Scholar 

  32. Gluer CC, Eastell R, Reid DM, et al.: Association of five quantitative ultrasound devices and bone densitometry with osteoporotic vertebral fractures in a population-based sample: the OPUS Study. J Bone Miner Res 2004, 19:782–793.

    Article  PubMed  Google Scholar 

  33. Bagger YZ, Tanko LB, Alexandersen P, et al.: The long-term predictive value of bone mineral density measurements for fracture risk is independent of the site of measurement and the age at diagnosis: results from the Prospective Epidemiological Risk Factors study. Osteoporos Int 2006, 17:471–477.

    Article  PubMed  Google Scholar 

  34. Porthouse J, Birks YF, Torgerson DJ, et al.: Risk factors for fracture in a UK population: a prospective cohort study. QJM 2004, 97:569–574.

    Article  PubMed  CAS  Google Scholar 

  35. Walley T, Mantgani A: The UK General Practice Research Database. Lancet 1997, 350:1097–1099.

    Article  PubMed  CAS  Google Scholar 

  36. Krieg MA, Cornuz J, Ruffieux C, et al.: Comparison of three bone ultrasounds for the discrimination of subjects with and without osteoporotic fractures among 7562 elderly women. J Bone Miner Res 2003, 18:1261–1266.

    Article  PubMed  CAS  Google Scholar 

  37. Anderson GL, Manson J, Wallace R, et al.: Implementation of the Women’s Health Initiative study design. Ann Epidemiol 2003, 13:S5–S17.

    Article  PubMed  Google Scholar 

  38. Yoshimura N, Takijiri T, Kinoshita H, et al.: Characteristics and course of bone mineral densities among fast bone losers in a rural Japanese community: the Miyama Study. Osteoporos Int 2004, 15:139–144.

    Article  PubMed  Google Scholar 

  39. Dargent-Molina P, Favier F, Grandjean H, et al.: Fall-related factors and risk of hip fracture: the EPIDOS prospective study. Lancet 1996, 348:145–149.

    Article  PubMed  CAS  Google Scholar 

  40. McGrother CW, Donaldson MM, Clayton D, et al.: Evaluation of a hip fracture risk score for assessing elderly women: the Melton Osteoporotic Fracture (MOF) study. Osteoporos Int 2002, 13:89–96.

    Article  PubMed  CAS  Google Scholar 

  41. Black DM, Steinbuch M, Palermo L, et al.: An assessment tool for predicting fracture risk in postmenopausal women. Osteoporos Int 2001, 12:519–528.

    Article  PubMed  CAS  Google Scholar 

  42. Kanis JA, Johnell O, De Laet C, et al.: International variations in hip fracture probabilities: implications for risk assessment. J Bone Miner Res 2002, 17:1237–1244.

    Article  PubMed  Google Scholar 

  43. Kanis JA, on behalf of the WHO Scientific Group: Assessment of osteoporosis at the primary health-care level. Technical Report. 2008. Available at http://www.shef.ac.uk/FRAX/reference.htm. Accessed August 14, 2009.

  44. van Staa TP, Leufkens HG, Abenhaim L, et al.: Oral corticosteroids and fracture risk: relationship to daily and cumulative doses. Rheumatology (Oxford) 2000, 39:1383–1389.

    Article  Google Scholar 

  45. Kanis JA, Johansson H, Johnell O, et al.: Alcohol intake as a risk factor for fracture. Osteoporos Int 2005, 16:737–742.

    Article  PubMed  Google Scholar 

  46. Delmas PD, Genant HK, Crans GG, et al.: Severity of prevalent vertebral fractures and the risk of subsequent vertebral and nonvertebral fractures: results from the MORE trial. Bone 2003, 33:522–532.

    Article  PubMed  CAS  Google Scholar 

  47. Johnell O, Kanis JA, Oden A, et al.: Fracture risk following an osteoporotic fracture. Osteoporos Int 2004, 15:175–179.

    Article  PubMed  CAS  Google Scholar 

  48. Kanis JA, Black D, Cooper C, et al.: A new approach to the development of assessment guidelines for osteoporosis. Osteoporos Int 2002, 13:527–536.

    Article  PubMed  CAS  Google Scholar 

  49. Orstavik RE, Haugeberg G, Mowinckel P, et al.: Vertebral deformities in rheumatoid arthritis: a comparison with population-based controls. Arch Intern Med 2004, 164:420–425.

    Article  PubMed  Google Scholar 

  50. Wainwright SA, Marshall LM, Ensrud KE, et al.: Hip fracture in women without osteoporosis. J Clin Endocrinol Metab 2005, 90:2787–2793.

    Article  PubMed  CAS  Google Scholar 

  51. Roy DK, Pye SR, Lunt M, et al.: Falls explain between-center differences in the incidence of limb fracture across Europe. Bone 2002, 31:712–717.

    Article  PubMed  CAS  Google Scholar 

  52. McClung MR, Geusens P, Miller PD, et al.: Effect of rise-dronate on the risk of hip fracture in elderly women. Hip Intervention Program Study Group. N Engl J Med 2001, 344:333–340.

    Article  PubMed  CAS  Google Scholar 

  53. Kayan K, Johansson H, Oden A, et al.: Can fall risk be incorporated into fracture risk assessment algorithms: a pilot study of responsiveness to clodronate. Osteoporos Int 2009 (in press).

  54. Kanis JA, McCloskey EV, Johansson H, et al.: Case finding for the management of osteoporosis with FRAX—assessment and intervention thresholds for the UK. Osteoporos Int 2008, 19:1395–1408.

    Article  PubMed  CAS  Google Scholar 

  55. Dawson-Hughes B, Tosteson AN, Melton LJ 3rd, et al.: Implications of absolute fracture risk assessment for osteoporosis practice guidelines in the USA. Osteoporos Int 2008, 19:449–458.

    Article  PubMed  CAS  Google Scholar 

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Correspondence to Eugene V. McCloskey.

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McCloskey, E.V., Johansson, H., Oden, A. et al. From relative risk to absolute fracture risk calculation: The FRAX algorithm. Curr Osteoporos Rep 7, 77–83 (2009). https://doi.org/10.1007/s11914-009-0013-4

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