Osteoporosis International

, Volume 28, Issue 1, pp 127–137 | Cite as

The FRAX-based Lebanese osteoporosis treatment guidelines: rationale for a hybrid model

  • M. ChakhtouraEmail author
  • W. D. Leslie
  • M. McClung
  • A. M. Cheung
  • G. El-Hajj Fuleihan
Original Article



We describe our approach to develop FRAX-based osteoporosis treatment guidelines in Lebanon, a country with low-moderate fracture rates. A hybrid assessment algorithm that combines a fixed 10 % intervention threshold until age 70 years, and an age-dependent threshold thereafter, was deemed most suitable.


The FRAX risk calculator is used to guide intervention thresholds in several national osteoporosis guidelines. This study aimed to describe the approach in developing FRAX-based osteoporosis treatment guidelines in Lebanon, a country with relatively low fracture rates.


We reassessed previous national guidelines combined with an evaluation of age-dependent and fixed FRAX-based intervention threshold models used in the UK, the USA, and Canada. We took into consideration the risk for major osteoporotic fractures (MOF) and the proportions of subjects considered for therapy using such thresholds, before finalizing a model for Lebanon.


The new Lebanese guidelines retained the recommendation to treat individuals with fragility fracture at the hip or spine. A femoral neck T-score ≤−2.5 in subjects without fractures was dropped, since it would imply consideration of therapy for individuals with a 10-year risk for MOF of <10 %, up to age 75 years in women. After considering the impact of both age-dependent and fixed intervention thresholds, we chose a new hybrid algorithm, combining a fixed 10 % treatment threshold until age 70 years and an age-dependent threshold thereafter.


The Lebanese FRAX-based hybrid model takes into consideration the risk for MOF and the proportions of subjects considered for treatment. This model avoids consideration of drug therapy in a large proportion of younger subjects at low risk for fracture and targets high risk elderly individuals. It was deemed most suitable for Lebanon and may be an option for other countries with relatively low fracture rates.


Age dependent intervention threshold Fixed intervention threshold FRAX Guidelines Osteoporosis 



The final hybrid assessment algorithm chosen was developed with contributions from the University of Sheffield Centre for Metabolic Bone Diseases WHO FRAX team, John A. Kanis, Eugene McCloskey, Anders Oden and Helena Johansson, and an international expert panel from the USA and Canada, Michael R. McClung, William D. Leslie, and Angela M. Cheung. The FRAX-based Lebanese guidelines were anchored on preceding national guidelines and reviewed, discussed, and unanimously endorsed by all members of the Lebanese National Task Force for Osteoporosis and Metabolic Bone Disorders, and nine Lebanese scientific societies registered with the Lebanese Order of Physicians. The Task Force Members are Asma Arabi, Ghada El-Hajj Fuleihan, George Halaby, and Ibrahim Salti (Endocrinology), Naji Attallah (Radiology), Rafic Baddoura, Jad Okais and Imad Uthman (Rheumatology), Muhieddine Seoud (Obstetrics and Gynecology), Assaad Taha (Orthopedics), Abdel Rahman El Hout and Asaad Khoury (Ministry of Health representatives), and Alissar Rady (WHO Lebanon representative). The endorsing societies are the Lebanese Society for Osteoporosis and Metabolic Bone Disorders (OSTEOS), the Lebanese Society of Endocrinology Diabetes and Lipids, the Lebanese Society of Obstetrics and Gynecology, the Lebanese Association of Orthopedic Surgeons, the Lebanese Society of Radiology, the Lebanese Society of Rheumatology, the Lebanese Society of Family Medicine, the Lebanese Society of Internal Medicine, the Lebanese Society of General Practitioners. The online website materials, executive summary, and relevant tables were developed by Marlene Chakhtoura and Ali Hammoudi.

The authors would like to thank the UK WHO FRAX team, John A. Kanis, Eugene McCloskey, Anders Oden, and Helena Johansson for their valuable contributions to develop the online FRAX Lebanon calculator and the Lebanese FRAX-based guidelines approach, including the implementation of simulation model calculations, and for providing the online national guidance based on the hybrid model. The authors would like to acknowledge Professors JA Kanis and E McCloskey for their helpful comments on the manuscript.

Compliance with ethical standards

Conflicts of interest

MC, GEHF, and WDL have no conflict of interest. MM has received honorarium and/or consulting fees from Amgen, Merck, and Radius. AM Cheung is supported by a Tier 1 Canada Research Chair in Musculoskeletal and Postmenopausal Health. AM Cheung has no conflicts of interests directly related to the work of this manuscript. Outside of this work, she has received grants (paid to institution) and/or consulting fees/honoraria from Amgen, Eli Lilly, and Merck.


This work that was supported by a grant from the Medical Resource Plan at the American University of Beirut, Lebanon and made possible thanks to the National Council for Scientific Research (CNRS). Research reported in this publication was supported by the Fogarty International Center and Office of Dietary Supplements of the National Institutes of Health under Award Number D43 TW009118. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.


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Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2016

Authors and Affiliations

  • M. Chakhtoura
    • 1
    Email author
  • W. D. Leslie
    • 2
  • M. McClung
    • 3
  • A. M. Cheung
    • 4
  • G. El-Hajj Fuleihan
    • 1
  1. 1.Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone DisordersAmerican University of Beirut Medical CenterBeirutLebanon
  2. 2.University of ManitobaWinnipegCanada
  3. 3.Oregon Osteoporosis CenterPortlandUSA
  4. 4.Centre of Excellence in Skeletal Health AssessmentUniversity Health Network, University of TorontoTorontoCanada

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