Many current guidelines for the assessment of osteoporosis, including those in Kuwait, initiate fracture risk assessment in men and women using BMD T-score thresholds. We compared the Kuwaiti guidelines with FRAX-based age-dependent intervention thresholds equivalent to that in women with a prior fragility fracture. FRAX-based intervention thresholds identified women at higher fracture probability than fixed T-score thresholds, particularly in the elderly.
A FRAX® model been recently calibrated for Kuwait, but guidance is needed on how to utilise fracture probabilities in the assessment and treatment of patients.
We compared age-specific fracture probabilities, equivalent to women with no clinical risk factors and a prior fragility fracture (without BMD), with the age-specific fracture probabilities associated with femoral neck T-scores of −2.5 and −1.5 SD, in line with current guidelines in Kuwait. Upper and lower assessment thresholds for BMD testing were additionally explored using FRAX.
When a BMD T-score of −2.5 SD was used as an intervention threshold, FRAX probabilities of a major osteoporotic fracture in women aged 50 years were approximately twofold higher than those in women of the same age but with an average BMD. The increase in risk associated with the BMD threshold decreased progressively with age such that, at the age of 83 years or more, a T-score of −2.5 SD was associated with a lower probability of fracture than that of the age-matched general population with no clinical risk factors. The same phenomenon was observed from the age of 66 years at a T-score of −1.5 SD. A FRAX-based intervention threshold, defined as the 10-year probability of a major osteoporotic fracture in a woman of average BMI with a previous fracture, rose with age from 4.3% at the age of 50 years to 23%, at the age of 90 years, and identified women at increased risk at all ages. Qualitatively comparable findings were observed in the case of hip fracture probability and in men.
Intervention thresholds based on BMD alone do not optimally target women at higher fracture risk than those on age-matched individuals without clinical risk factors, particularly in the elderly. In contrast, intervention thresholds based on fracture probabilities equivalent to a ‘fracture threshold’ consistently target women at higher fracture risk, irrespective of age.
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Kanis JA, Melton LJ, Christiansen C, Johnston C, Khaltaev N (1994) The diagnosis of osteoporosis. J Bone Miner Res 9:1137–1141
Kanis JA, McCloskey EV, Johansson H, Oden A, Melton LJ 3rd, Khaltaev N (2008) A reference standard for the description of osteoporosis. Bone 42:467–475
World Health Organisation (1994) assessment of fracture risk and its application to screening for postmenopausal osteoporosis. WHO Technical Report Series 843. 1994. WHO, Geneva
Kanis JA, Johnell O, De Laet C et al (2004a) A meta-analysis of previous fracture and subsequent fracture risk. Bone 35:375–382
Kanis JA, Johansson H, Oden A et al (2004) A family history of fracture and fracture risk: a meta-analysis. Bone 35:1029–1037
Feskanich D, Willett W, Colditz G (2002) Walking and leisure-time activity and risk of hip fracture in postmenopausal women. JAMA 288:2300–2306
Kanis JA, Johnell O, Oden A et al (2005) Smoking and fracture risk: a meta-analysis. Osteoporos Int 16:155–162
Kanis JA on behalf of the World Health Organization Scientific Group (2008a) Assessment of osteoporosis at the primary health-care level. Technical Report. WHO Collaborating Centre, University of Sheffield, UK
Kanis JA, Johnell O, Oden A, Johansson H, McCloskey E (2008b) FRAX™ and the assessment of fracture probability in men and women from the UK. Osteoporos Int 19:385–397
Kanis JA, Odén A, McCloskey EV, Johansson H, Wahl D, Cyrus Cooper C on behalf of the IOF Working Group on Epidemiology and Quality of Life (2012) A systematic review of hip fracture incidence and probability of fracture worldwide. Osteoporos Int 23:2239–2256
Oden A, McCloskey EV, Kanis JA, Harvey NC, Johansson H (2015) Burden of high fracture probability worldwide: secular increases 2010-2040. Osteoporos Int 26:2243–2248
Kanis JA, Harvey NC, Cooper C, Johansson H, Odén A, McCloskey EV, the Advisory Board of the National Osteoporosis Guideline Group (2016) A systematic review of intervention thresholds based on FRAX. Arch Osteoporos 11(1):25
Azizieh FY (2015) Incidence of hip fracture in Kuwait: a national registry-based study Arch Osteoporos 10: 40
Kuwait Osteoporosis Society (2014) 2014 Kuwait osteoporosis society guidelines for the screening and treatment of osteoporosis Accessed 28 Sept 2016, www.kops-kw.org/GuideLines.aspx
Cosman F, de Beur SJ, LeBoff MS et al (2014) Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int 25:2359–2381
Scottish Intercollegiate Guidelines Network (SIGN) (2015) Management of osteoporosis and the prevention of fragility fractures. Edinburgh: SIGN; 2015. (SIGN publication no. 142). http://www.sign.ac.uk. Accessed May 11 2015
Kanis JA, McCloskey, EV, Johansson H, Strom O, Borgstrom F, Oden A and the National Osteoporosis Guideline Group (2008c) Case finding for the management of osteoporosis with FRAX®—assessment and intervention thresholds for the UK. Osteoporos Int 19: 1395-1408 erratum 2009. Osteoporos Int 20: 499–502
Compston J, Cooper A, Cooper C, On behalf of the National Osteoporosis Guideline Group (NOGG) et al (2009) Guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK. Maturitas 62:105–108
Newkuwat. The public authority for civil information. https://www.paci.gov.kw/ accessed 30 june 2106
Kanis JA, Oden A, Johnell O et al (2007) The use of clinical risk factors enhances the performance of BMD in the prediction of hip and osteoporotic fractures in men and women. Osteoporos Int 18:1033–1046
Johansson H, Oden A, Johnell O et al (2004) Optimization of BMD measurements to identify high risk groups for treatment—a test analysis. J Bone Miner Res 19:906–913
Leslie WD, Majumdar SR, Lix LM et al (2012) High fracture probability with FRAX usually indicates densitometric osteoporosis: implications for clinical practice. Osteoporos Int 23:391–397
Kanis JA, McCloskey E, Johansson H, Oden A, Leslie WD (2012) FRAX(®) with and without bone mineral density. Calcif Tissue Int 90:1–13
Marshall D, Johnell O, Wedel H (1996) Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. Br Med J 312(7041):1254–1259
Johnell O, Kanis JA, Oden A, Johansson H, De Laet C, Delmas P et al (2005) Predictive value of BMD for hip and other fractures. J Bone Miner Res 20:1185–1194
Grigorie D, Sucaliuc A, Johansson H, Kanis JA, McCloskey E (2013) FRAX-based intervention and assessment thresholds for osteoporosis in Romania. Arch Osteoporos 8:164
Kanis JA, Compston J, Cooper C, Harvey NC, Johansson H, Odén A, McCloskey EV (2016) SIGN guidelines for Scotland: BMD versus FRAX versus QFracture. Calcif Tissue Int 98:417–425
Kanis JA, Johnell O (2005) Requirements for DXA for the management of osteoporosis in Europe. Osteoporos Int 16:229–238
Lekamwasam S, Adachi JD, Agnusdei D et al (2012) A framework for the development of guidelines for the management of glucocorticoid-induced osteoporosis. Osteoporos Int 23:2257–2276
Kanis JA, McCloskey EV, Johansson H, Cooper C, Rizzoli R, Reginster JY (2013) European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 24:23–57
Johansson H, Kanis JA, Oden A, Compston J, McCloskey E (2012) A comparison of case-finding strategies in the UK for the management of hip fractures. Osteoporos Int 23:907–915
Kanis JA, McCloskey EV, Harvey NC, Johansson H, Leslie WD (2015) Intervention thresholds and the diagnosis of osteoporosis. J Bone Miner Res 30:1747–1753
Conflicts of interest
Professor Kanis led the team that developed FRAX as director of the then WHO collaborating centre for metabolic bone diseases; he has no financial interest in FRAX. Professors McCloskey, Oden, Harvey and Dr. Johansson are members of the FRAX team. Professors Harvey, Kanis and McCloskey are members of the Expert Advisory Group of the National Osteoporosis Guideline Group, UK.
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Johansson, H., Azizieh, F., al Ali, N. et al. FRAX- vs. T-score-based intervention thresholds for osteoporosis. Osteoporos Int 28, 3099–3105 (2017). https://doi.org/10.1007/s00198-017-4160-7
- Fracture probability
- Intervention threshold