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FRAX-based intervention thresholds for Pakistan

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Abstract

Summary

We compared, for women in Pakistan, the utility of intervention thresholds either at a T-score ≤  − 2.5 or based on a FRAX probability equivalent to women of average body mass index (BMI) with a prior fragility fracture. Whereas the FRAX-based intervention threshold identified women at high fracture probability, the T-score threshold was less sensitive, and the associated fracture risk decreased markedly with age.

Purpose

The fracture risk assessment algorithm FRAX® has been recently calibrated for Pakistan, but guidance is needed on how to apply fracture probabilities to clinical practice.

Methods

The age-specific 10-year probabilities of a major osteoporotic fracture were calculated in women with average BMI to determine fracture probabilities at two potential intervention thresholds. The first comprised the age-specific fracture probabilities associated with a femoral neck T-score of − 2.5. The second approach determined age-specific fracture probabilities that were equivalent to a woman with a prior fragility fracture, without bone mineral density (BMD). The parsimonious use of BMD was additionally explored by the computation of upper and lower assessment thresholds for BMD testing.

Results

When a BMD T-score ≤  − 2.5 was used as an intervention threshold, FRAX probabilities in women aged 50 years were approximately two-fold higher than in women of the same age but with no risk factors and average BMD. The relative increase in risk associated with the BMD threshold decreased progressively with age such that, at the age of 80 years or more, a T-score of − 2.5 was actually protective. The 10-year probability of a major osteoporotic fracture by age, equivalent to women with a previous fracture, rose with age from 2.1% at the age of 40 years to 17%, at the age of 90 years, and identified women at increased risk at all ages.

Conclusion

Intervention thresholds based on BMD alone do not effectively target women at high fracture risk, particularly in the elderly. In contrast, intervention thresholds based on fracture probabilities equivalent to a ‘fracture threshold’ target women at high fracture risk.

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Author information

Authors and Affiliations

  1. Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia

    H. Johansson, E. Liu, L. Vandenput, M. Lorentzon & J. A. Kanis

  2. Centre for Metabolic Bone Diseases, University of Sheffield, Beech Hill Road, Sheffield, S10 2RX, UK

    H. Johansson, E. V. McCloskey & J. A. Kanis

  3. Sahlgrenska Osteoporosis Centre, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden

    H. Johansson & M. Lorentzon

  4. Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia

    G. Naureen

  5. Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Western Health, Melbourne, Australia

    G. Naureen

  6. Departments of Community Health Sciences and Medicine, Aga Khan University, Karachi, Pakistan

    R. Iqbal

  7. Department of Pathology & Laboratory Medicine, Aga Khan University, Karachi, Pakistan

    L. Jafri & A. H. Khan

  8. Department of Orthopaedics, Aga Khan University, Karachi, Pakistan

    M. Umer

  9. Centre for Bone and Arthritis Research, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

    L. Vandenput

  10. Department of Oncology and Metabolism, Mellanby Centre for Musculoskeletal Research, University of Sheffield, Sheffield, UK

    E. V. McCloskey

  11. MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK

    N. C. Harvey

  12. NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK

    N. C. Harvey

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  1. H. Johansson
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  2. G. Naureen
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  3. R. Iqbal
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  5. A. H. Khan
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  6. M. Umer
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  7. E. Liu
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  8. L. Vandenput
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  10. E. V. McCloskey
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  11. J. A. Kanis
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Correspondence to J. A. Kanis.

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Conflicts of interest

G Naureen, H Johansson, E Liu, L Vandenput, M Lorentzon, NC Harvey, E. McCloskey, and JA Kanis declare that they have no competing interests in relation to this paper. HJ, EM, NCH, and JAK are the architects of FRAX in which they have no financial interest. JAK is editor in chief of the European office of Osteoporosis International. The manuscript was independently reviewed by the US office.

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Johansson, H., Naureen, G., Iqbal, R. et al. FRAX-based intervention thresholds for Pakistan. Osteoporos Int 33, 105–112 (2022). https://doi.org/10.1007/s00198-021-06087-y

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