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Fracture Risk Assessment (FRAX) Tool

Original Editor - Carin Hunter

Top Contributors - Carin Hunter, Kim Jackson, Shaheen Begum and Vidya Acharya  

Introduction

FRAX, short for Fracture Risk Assessment Tool, is primarily a screening tool and provides country-specific algorithms for estimating individualized 10-year probability of hip and major osteoporotic fracture[1] and to target anti-osteoporosis treatments[2]. It was created in 2008 at the University of Sheffield in the United Kingdom by the World Health Organization (WHO) Collaborating Centre for Metabolic Bone Diseases.

Many risk factors for fractures were identified and added to the tool through a series of comprehensive meta analyses from 12 prospective population-based studies from North America, Europe, Asia, and Australia. The tool's ease of use and accessibility in primary care was one of its core goals.[3]

FRAX uses seven easily accessible clinical risk factors, which are entered into the calculation as yes or no. These factors include smoking, systemic glucocorticoid usage, excessive alcohol consumption, rheumatoid arthritis, parental hip fractures, past fragility fractures, and other causes of secondary osteoporosis. FRAX also takes into account body mass index (BMI), sex, and age. When a densitometric evaluation is not available, FRAX may calculate the fracture probability with or without femoral neck BMD, accommodating different situations.[3]

With its inclusion in more than 100 international guidelines, FRAX is the most widely used instrument for assessing fracture risk worldwide. It can be utilized to most effectively facilitate assessment with BMD in addition to guiding treatment recommendations. Both the cost-effectiveness of these strategies and the potential value of FRAX as the cornerstone of strategies for population screening for high fracture risk have been established.[3]

Intended Population

The FRAX calculator is used to to evaluate fracture risk of patients and can be used by a healthcare professional within their clinical decision making process to know what intervention to best recommend. These interventions could incorporate pharmaceutical referral, an exercise program or nutritional changes.

Method of Use

To use the FRAX calculator, go to the FRAX calculator[4] on the Sheffield University website,

Click on the dropdown "CALCULATION TOOL" in the top panel and select the continent and country.

There are 2 components to the calculation

  1. The place you were born
  2. The place you currently live

The most accurate picture of bone health is to work out both scores and conduct a comparison. The initial calculation will give an idea of the genetic component while the second figure will incorporate information on your bone health related to sun exposure and diet.

The following information is then required

  • Age, date of birth, sex, weight and height
  • Previous and parent fracture history
  • Smoking status
  • Glucocorticoid steroid usage history
  • Rheumatoid arthritis
  • Secondary osteoporosis
  • Alcohol consumption
  • Femoral neck bone mineral density (BMD)

The results can then be calculated

FRAX Score Interpretation

After results have been calculated, you will see a "red box score". This shows the BMI and the 10-year probability of a fracture

[5]

In Exercise for Better Bones[6], the cardiovascular (or weight bearing) exercise recommendations fall into three categories:

  1. Low Fracture Risk.
  2. Moderate Fracture Risk.
  3. High Fracture Risk

How to Adjust the T-Score Result

The FRAX calculator is specific to populations and geographical locations. You may need to adjust your T-score for your patients particular demographic. The adjustment tool can be found online at the University of Washington[7] website

After adjusting the T-score, use the normalized T-score in the FRAX calculator to continue and get your FRAX score.

[5]

Margaret Martin, physical therapist, has created a video tutorial on how to convert the T-score to be more specific to your patient.

Limitations

FRAX has faced criticism over the years, primarily due to its limited quantity and level of detail in risk factor selection. Risk factors that depend on numbers or doses are not completely accounted for. Examples include the amount of alcohol consumed, the number of previous fractures, and the glucocorticoid dosage. The absence of assessments of the composition or structural characteristics of bone and the lack of support for lumbar spine BMD are further issues. It may be interesting to consider the age of the parental fracture.[3] Furthermore, the FRAX calculator does not account for the levels of calcium, vitamin K, vitamin D, or other nutrients, or the use of drugs that may have an impact on bone health.[5]

New developments

Several studies have suggested making arithmetic adjustments to the traditional FRAX probabilities over time to mitigate some of its limitations.[3] Adjustments in the FRAX (%) based on the dose of glucocorticoids were proposed as a resolution to the glucocorticoid issue. [8]Recently, a study has produced probability ratios or multipliers that can be applied based on the number of falls over the last year, in the lack of a direct question relating to falls history in FRAX and suggesting potential changes. [9]

Additionally, probability ratios have been provided based on the recency of fractures.[10][11] The following rule has been proposed when BMD at the lumbar spine (LS) is available and there is discrepancy between this result and that at the femoral neck (FN), to increase/decrease FRAX estimate for a major fracture by one-tenth for each rounded T-score difference (10% per SD).[12]

There are times when both hip axis length and trabecular bone score (TBS) are available, and they can be used to assess changes in fracture risk.[13][14] In instances of type 2 diabetes mellitus, a few modifications have been suggested, such as using the rheumatoid arthritis (RA) input or adjusting with Trabecular bone score (TBS).[15] For Parkinson's disease, an identical method (using the RA output) has been suggested. [16]

Geographical origin can also influence FRAX probability, as demonstrated by a Swedish study where the prevalence of hip fractures among Swedish-born individuals was around double that of those born outside the nation.[17] Moreover, there was a gradual rise in the incidence of hip fractures due to immigration (0.6% per year). It was proposed that while using FRAX, the birth country be used.[17]

While the user has the option to modify the fracture probability output generated by FRAX, FRAXplus is another website that allows the user to automatically apply these effect modifiers. The availability of additional cohorts and extended follow-up in existing cohorts, along with the opportunity to alter FRAX probability using the new FRAXplus website , will support the development of the second version of the main FRAX tool itself.[3]

FRAX was originally designed for use in the general population but recently clinicians have been applying the FRAX tool to individuals with special conditions.

Globally breast cancer is the most common cancer in women[18]. Aromatase inhibitor (AI) therapy is recommended to reduce the risk of cancer recurrence in postmenopausal women with hormone receptor–positive breast cancer[19] This treatment has been reported to increase bone turnover, bone loss, and fracture risk[20]. Denosumab is a pharmaceutical options to prevent bone loss in AI users[21][22][23]. One paper has recommended FRAX for guidance on prevention of bone loss and fractures in postmenopausal women treated with AI for breast cancer [24]. The accuracy of this application is unknown as the FRAX tool was not designed for this application.[23]

Resources

FRAX ®Fracture Risk Assessment Tool developed by The University of Sheffield

References

  1. ↑ Kanis JA, Harvey NC, Johansson H, Liu E, Vandenput L, Lorentzon M, Leslie WD, McCloskey EV. A decade of FRAX: how has it changed the management of osteoporosis?. Aging clinical and experimental research. 2020 Feb;32(2):187-96.
  2. ↑ Kanis JA, Johansson H, Harvey NC, McCloskey EV. A brief history of FRAX. Archives of osteoporosis. 2018 Dec;13(1):1-6.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Schini, M. & Johansson, H. & Harvey, N. & Lorentzon, Mattias & Kanis, J. & McCloskey, E.. (2023). An overview of the use of the fracture risk assessment tool (FRAX) in osteoporosis. Journal of Endocrinological Investigation. 47. 10.1007/s40618-023-02219-9.
  4. ↑ https://www.sheffield.ac.uk/FRAX/
  5. ↑ 5.0 5.1 5.2 https://melioguide.com/frax/
  6. ↑ https://melioguide.com/products/exercise-for-better-bones-program/
  7. ↑ http://courses.washington.edu/bonephys/opbmdtz.html
  8. ↑ Kanis JA, Johansson H, Oden A, Mccloskey EV (2011) Guidance for the adjustment of FRAX according to the dose of glucocorticoids. Osteoporos Int 22:809–816.
  9. ↑ Masud T, Binkley N, Boonen S, Hannan MT, Members FPDC (2011) Official positions for FRAX® clinical regarding falls and frailty: can falls and frailty be used in FRAX®? from joint official positions development conference of the international society for clinical densitometry and international osteoporosis foundation on FRAX® (in eng). J Clin Densitom 14:194–204.
  10. ↑ Kanis JA, Johansson H, Harvey NC, Gudnason V, Sigurdsson G, Siggeirsdottir K, Lorentzon M, Liu E, Vandenput L, Mccloskey EV (2022) Adjusting conventional FRAX estimates of fracture probability according to the number of prior fractures. Osteoporos Int 33:2507–2515.
  11. ↑ Leslie WD, Morin SN, Lix LM, Martineau P, Bryanton M, Mccloskey EV, Johansson H, Harvey NC, Kanis JA (2019) Fracture prediction from self-reported falls in routine clinical practice: a registry-based cohort study. Osteoporos Int 30:2195–2203.
  12. ↑ Leslie WD, Lix LM, Johansson H, Oden A, Mccloskey E, Kanis JA (2011) Spine–hip discordance and fracture risk assessment: a physician-friendly FRAX enhancement. Osteoporos Int 22:839– 847.
  13. ↑ . Leslie WD, Lix LM, Morin SN, Johansson H, Odén A, McCloskey EV, Kanis JA (2016) Adjusting hip fracture probability in men and women using hip axis length: the manitoba bone density database (in eng). J Clin Densitom 19:326–331.
  14. ↑ Mccloskey EV, Odén A, Harvey NC, Leslie WD, Hans D, Johansson H, Kanis JA (2015) Adjusting fracture probability by trabecular bone score. Calcif Tissue Int 96:500–509.
  15. ↑ Leslie WD, Johansson H, Mccloskey EV, Harvey NC, Kanis JA, Hans D (2018) Comparison of methods for improving fracture risk assessment in diabetes: the Manitoba BMD registry. J Bone Miner Res 33:1923–1930.
  16. ↑ Schini M, Bhatia P, Shreef H, Johansson H, Harvey NC, Lorentzon M, Kanis JA, Bandman O, McCloskey EV (2022) Increased fracture risk in Parkinson’s disease-an exploration of mechanisms and consequences for fracture prediction with FRAX (in eng). Bone.
  17. ↑ 17.0 17.1 Johansson H, Odén A, Lorentzon M, Mccloskey E, Kanis JA, Harvey NC, Karlsson MK, Mellström D (2015) Is the Swedish FRAX model appropriate for Swedish immigrants? Osteoporos Int 26:2617–2622.
  18. ↑ Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians. 2018 Nov;68(6):394-424.
  19. ↑ Burstein HJ, Temin S, Anderson H, Buchholz TA, Davidson NE, Gelmon KE, Giordano SH, Hudis CA, Rowden D, Solky AJ, Stearns V. Adjuvant endocrine therapy for women with hormone receptor–positive breast cancer: American Society of Clinical Oncology clinical practice guideline focused update. Journal of clinical oncology. 2014 Jul 20;32(21):2255.
  20. ↑ Reid DM, Doughty J, Eastell R, Heys SD, Howell A, McCloskey EV, Powles T, Selby P, Coleman RE. Guidance for the management of breast cancer treatment-induced bone loss: a consensus position statement from a UK Expert Group. Cancer treatment reviews. 2008 Jan 1;34:S3-18.
  21. ↑ Gnant M, Pfeiler G, Dubsky PC, Hubalek M, Greil R, Jakesz R, Wette V, Balic M, Haslbauer F, Melbinger E, Bjelic-Radisic V. Adjuvant denosumab in breast cancer (ABCSG-18): a multicentre, randomised, double-blind, placebo-controlled trial. The Lancet. 2015 Aug 1;386(9992):433-43.
  22. ↑ Greenspan SL, Vujevich KT, Brufsky A, Lembersky BC, van Londen GJ, Jankowitz RC, Puhalla SL, Rastogi P, Perera S. Prevention of bone loss with risedronate in breast cancer survivors: a randomized, controlled clinical trial. Osteoporosis International. 2015 Jun;26(6):1857-64.
  23. ↑ 23.0 23.1 Rizzoli R, Body JJ, De Censi A, Reginster JY, Piscitelli P, Brandi ML. Guidance for the prevention of bone loss and fractures in postmenopausal women treated with aromatase inhibitors for breast cancer: an ESCEO position paper. Osteoporosis international. 2012 Nov;23(11):2567-76.
  24. ↑ Leslie WD, Morin SN, Lix LM, Niraula S, McCloskey EV, Johansson H, Harvey NC, Kanis JA. Performance of FRAX in Women with Breast Cancer Initiating Aromatase Inhibitor Therapy: A Registry‐Based Cohort Study. Journal of Bone and Mineral Research. 2019 Aug;34(8):1428-35.
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