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FRAX-based intervention and assessment thresholds for osteoporosis in Iran

  • P. Khashayar
  • A. Keshtkar
  • A. Ostovar
  • B. LarijaniEmail author
  • H. Johansson
  • N.C. Harvey
  • M. Lorentzon
  • E. McCloskey
  • J.A. Kanis
Original Article

Abstract

Summary

We compared the utility of the current Iranian guidelines that recommend treatment in women with a T-score ≤ − 2.5 SD with a FRAX-based intervention threshold equivalent to women of average 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.

Introduction

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

Methods

The age-specific ten-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 SD, in line with current guidelines in Iran. The second approach determined age-specific fracture probabilities that were equivalent to a woman with a prior fragility fracture, without 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 SD was used as an intervention threshold, FRAX probabilities in women aged 50 years was approximately two-fold higher than in women of the same age but with an average BMD and no risk factors. 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 SD 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 4.9% at the age of 50 years to 17%, at the age of 80 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.

Keywords

FRAX Fracture probability Guidelines Intervention threshold Iran Osteoporosis 

Notes

Acknowledgments

This paper is based on a similar paper prepared for Romania [21] but uses the Iranian rather than Romanian FRAX model.

Compliance with ethical standards

Conflicts of interest

None.

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Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2019

Authors and Affiliations

  1. 1.Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences InstituteTehran University of Medical SciencesTehranIran
  2. 2.Center for Microsystems TechnologyImec and Ghent UniversityGent-ZwijnaardeBelgium
  3. 3.Department of Health Sciences Education Development, School of Public HealthTehran University of Medical SciencesTehranIran
  4. 4.Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences InstituteTehran University of Medical SciencesTehranIran
  5. 5.Mary McKillop Health InstituteAustralian Catholic UniversityMelbourneAustralia
  6. 6.Centre for Metabolic Bone DiseasesUniversity of SheffieldSheffieldUK
  7. 7.MRC Lifecourse Epidemiology UnitUniversity of SouthamptonSouthamptonUK
  8. 8.NIHR Southampton Biomedical Research CentreUniversity of Southampton and University Hospital Southampton NHS Foundation TrustSouthamptonUK
  9. 9.Geriatric Medicine, Institute of MedicineUniversity of GothenburgGothenburgSweden
  10. 10.Department of Geriatric MedicineSahlgrenska University HospitalMölndalSweden
  11. 11.Centre for Integrated research in Musculoskeletal Ageing (CIMA), Mellanby Centre for Bone ResearchUniversity of SheffieldSheffieldUK

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