Osteoporosis International

, 22:2395 | Cite as

Interpretation and use of FRAX in clinical practice

  • J. A. KanisEmail author
  • D. Hans
  • C. Cooper
  • S. Baim
  • J. P. Bilezikian
  • N. Binkley
  • J. A. Cauley
  • J. E. Compston
  • B. Dawson-Hughes
  • G. El-Hajj Fuleihan
  • H. Johansson
  • W. D. Leslie
  • E. M. Lewiecki
  • M. Luckey
  • A. Oden
  • S. E. Papapoulos
  • C. Poiana
  • R. Rizzoli
  • D. A. Wahl
  • E. V. McCloskey
  • Task Force of the FRAX Initiative
Position Paper



The introduction of the WHO FRAX® algorithms has facilitated the assessment of fracture risk on the basis of fracture probability. Its use in fracture risk prediction has strengths, but also limitations of which the clinician should be aware and are the focus of this review


The International Osteoporosis Foundation (IOF) and the International Society for Clinical Densitometry (ISCD) appointed a joint Task Force to develop resource documents in order to make recommendations on how to improve FRAX and better inform clinicians who use FRAX. The Task Force met in November 2010 for 3 days to discuss these topics which form the focus of this review.


This study reviews the resource documents and joint position statements of ISCD and IOF.


Details on the clinical risk factors currently used in FRAX are provided, and the reasons for the exclusion of others are provided. Recommendations are made for the development of surrogate models where country-specific FRAX models are not available.


The wish list of clinicians for the modulation of FRAX is large, but in many instances, these wishes cannot presently be fulfilled; however, an explanation and understanding of the reasons may be helpful in translating the information provided by FRAX into clinical practice.


Bone mineral density Clinical risk factors Fracture probability Risk assessment 



This paper was reviewed and endorsed by the Committee of Scientific Advisors of the IOF. The FRAX Initiative comprised the organisers, task force liaisons, the members of the three Task Forces and the expert panel.


Didier Hans (Co-chair), Cyrus Cooper (co-chair), Sanford Baim, Bess Dawson-Hughes, John A Kanis, William D Leslie, Marjory Lucky, Rene Rizzoli, Catalina Poiana, John P Bilezikian (moderator) and Socrates E Papapoulos (moderator).

FRAX Clinical

Eugene McCloskey (Chair); Neil Binkley (Co-chair); Jonathan Adachi and Sanford Baim (programme committee liaison); Dennis Black, Robert Blank, Susan Broy and Bess Dawson-Hughes (programme committee liaison) and Sergio Ortolani, Hans Peter Dimai, Michael Kleerekoper, Marc-Antoine Krieg, Bente Langdahl, Andrew Laster, Edward Leib, Tahir Masud, Mike McClung, Rene Rizzoli, Kenneth Saag and Ethel Siris.


E Michael Lewiecki (Chair); Juliet Compston (Co-chair); Jonathan Adachi Judith Adams, Robert Adler, Doug Bauer Glen Blake, Patricia Clark, Adolfo Diez-Perez, Didier Hans and John A Kanis (programme committee liaison); Marc-Antoine Krieg, Didier Hans and William Leslie (programme committee liaison) and Alireza Moayyeri, Robert Josse, David Kendler, Aliya Khan, Brian Lentle, Roman Lorenc, Basel Masri and Paul Miller.

FRAX International

Jane Cauley (Chair); Ghada El-Hajj Fuleihan (Co-chair); Asma Arabi, Andrew Calderon, Zhao Chen, Siok Bee Chinoh, Jeffry Curtis, Michelle Danielson, Saeko Fujiwara, David Hanley, Heikki Kroger, Annie Kung, Olga Lesnyak, Anne Looker and Marjorie Luckey (programme committee liaison); Dan Mellstrom, Jeri Nieves, Wojciech Pluskiewicz, Rola El Rassi and René Rizzoli (programme committee liaison) and Sergio Ragi-Eis, Anna Marie Schott-Pethelaz and Stuart Silverman.

Expert panel

Socrates E Papapoulos (moderator), John P Bilezikian (moderator) and Jonathan Adachi, Robert D Blank, Roland Chapurlat, Wu (Paulo) Chih-Hsing, Edward Czerwinski, Aldolfo Diez-Perez, Hans Peter Dimai, Ghada El-Hajj Fuleihan, Saeko Fujiwara, Ruxandra M Ionescu, John A Kanis, Mike McClung, Paul Miller, Sergio Ragi-Eis, Jan Stepan, Kenneth Saag, John T Schousboe, Wei Yu and Cristiano Zerbini.

Support staff

Peter D. Brown (ISCD), Patrice McKenney (IOF) and Helena Johansson, Judit Nagy, Anders Oden and Denys A Wahl.

Conflicts of interest

S Baim, JP Bilezikian, JE Compston, G El-Hajj Fuleihan, A Oden, B Dawson-Hughes, EM Lewiecki, DA Wahl, H Johansson and D Hans have no competing interests to declare with regard to this manuscript. JA Kanis and E McCloskey: Consulting fees, paid advisory boards, lecture fees, and/or grant support from the majority of companies concerned with skeletal metabolism. WD Leslie: Speaker fees and unrestricted research grants from Amgen and Merck Frosst; unrestricted research grants from Sanofi-Aventis, Warner Chilcott (formerly Procter & Gamble), Novartis, Amgen, Genzyme; advisory boards for Genzyme, Novartis, and Amgen. J Cauley: Consultant to Novartis for the HORIZON steering committee and receives research funding for the HORIZON trial. C Cooper: Consulting fees and paid advisory boards for Alliance for Better Bone Health, Glaxo Smith Kline, Roche, Merck Sharp and Dohme, Lilly, Amgen, Wyeth, Novartis, Servier, and Nycomed. R Rizzoli: Paid advisory boards and lecture fee for Merck Sharp and Dohme, Eli Lilly, Amgen, Wyeth, Novartis, Servier, Nycomed, and Danone. N Binkley: Consulting fees and research support from Amgen, Lilly, Merck and Tarsa. M Luckey: Consulting fees and lecture fees from Merck Sharp and Dohme, Eli Lilly, Amgen, Novartis and Tarsa Pharmaceuticals. C Poiana: Lecture fees and paid advisory boards for Amgen, Merck Sharp and Dohme, Glaxo Smith Kline and Novartis. S Papapoulos: Consulting and/or lecture fees from Alliance for Better Bone Health, Amgen, Eli Lilly, Glaxo Smith Kline, Merck & Co, Novartis and Wyeth.


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Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2011

Authors and Affiliations

  • J. A. Kanis
    • 1
    Email author
  • D. Hans
    • 2
  • C. Cooper
    • 3
    • 4
  • S. Baim
    • 5
  • J. P. Bilezikian
    • 6
  • N. Binkley
    • 7
  • J. A. Cauley
    • 8
  • J. E. Compston
    • 9
  • B. Dawson-Hughes
    • 10
  • G. El-Hajj Fuleihan
    • 11
  • H. Johansson
    • 12
  • W. D. Leslie
    • 13
  • E. M. Lewiecki
    • 14
  • M. Luckey
    • 15
  • A. Oden
    • 12
  • S. E. Papapoulos
    • 16
  • C. Poiana
    • 17
  • R. Rizzoli
    • 18
  • D. A. Wahl
    • 19
  • E. V. McCloskey
    • 20
  • Task Force of the FRAX Initiative
  1. 1.WHO Collaborating Centre for Metabolic Bone DiseasesUniversity of Sheffield Medical SchoolSheffieldUK
  2. 2.Center of Bone Diseases, Bone and Joint DepartmentLausanne University HospitalLausanneSwitzerland
  3. 3.MRC Lifecourse Epidemiology UnitUniversity of SouthamptonSouthamptonUK
  4. 4.NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal SciencesUniversity of OxfordOxfordUK
  5. 5.Division of EndocrinologyUniversity of Miami, Miller School of MedicineCoral GablesUSA
  6. 6.Columbia University College of Physicians and SurgeonsNew YorkUSA
  7. 7.Osteoporosis Clinical Research ProgramUniversity of WisconsinMadisonUSA
  8. 8.Department of Epidemiology, Graduate School of Public HealthUniversity of PittsburghPittsburghUSA
  9. 9.Department of Medicine, Addenbrooke’s HospitalCambridge UniversityCambridgeUK
  10. 10.Jean Mayer United States Department of Agriculture Human Nutrition Research Center on AgingTufts UniversityBostonUSA
  11. 11.WHO Collaborating Center for Metabolic Bone DisordersAmerican University of BeirutBeirutLebanon
  12. 12.Centre for Bone Research at the Sahlgrenska Academy, Institute of MedicineUniversity of GothenburgGothenburgSweden
  13. 13.University of ManitobaWinnipegCanada
  14. 14.New Mexico Clinical Research & Osteoporosis CenterUniversity of New Mexico School of MedicineAlbuquerqueUSA
  15. 15.St. Barnabas Osteoporosis & Metabolic Bone Disease CenterLivingstonUSA
  16. 16.Department of Endocrinology and Metabolic DiseasesLeiden University Medical CenterLeidenthe Netherlands
  17. 17.Department of EndocrinologyCarol Davila University of Medicine and PharmacyBucharestRomania
  18. 18.Division of Bone Diseases, Department of Rehabilitation and GeriatricsGeneva University Hospitals and Faculty of MedicineGenevaSwitzerland
  19. 19.International Osteoporosis FoundationNyonSwitzerland
  20. 20.Academic Unit of Bone MetabolismUniversity of SheffieldSheffieldUK

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