This systematic review identified assessment guidelines for osteoporosis that incorporate FRAX. The rationale for intervention thresholds is given in a minority of papers. Intervention thresholds (fixed or age-dependent) need to be country-specific.
In most assessment guidelines, treatment for osteoporosis is recommended in individuals with prior fragility fractures, especially fractures at spine and hip. However, for those without prior fractures, the intervention thresholds can be derived using different methods. The aim of this report was to undertake a systematic review of the available information on the use of FRAX® in assessment guidelines, in particular the setting of thresholds and their validation.
We identified 120 guidelines or academic papers that incorporated FRAX of which 38 provided no clear statement on how the fracture probabilities derived are to be used in decision-making in clinical practice. The remainder recommended a fixed intervention threshold (n = 58), most commonly as a component of more complex guidance (e.g. bone mineral density (BMD) thresholds) or an age-dependent threshold (n = 22). Two guidelines have adopted both age-dependent and fixed thresholds.
Fixed probability thresholds have ranged from 4 to 20 % for a major fracture and 1.3–5 % for hip fracture. More than one half (39) of the 58 publications identified utilised a threshold probability of 20 % for a major osteoporotic fracture, many of which also mention a hip fracture probability of 3 % as an alternative intervention threshold. In nearly all instances, no rationale is provided other than that this was the threshold used by the National Osteoporosis Foundation of the USA. Where undertaken, fixed probability thresholds have been determined from tests of discrimination (Hong Kong), health economic assessment (USA, Switzerland), to match the prevalence of osteoporosis (China) or to align with pre-existing guidelines or reimbursement criteria (Japan, Poland). Age-dependent intervention thresholds, first developed by the National Osteoporosis Guideline Group (NOGG), are based on the rationale that if a woman with a prior fragility fracture is eligible for treatment, then, at any given age, a man or woman with the same fracture probability but in the absence of a previous fracture (i.e. at the ‘fracture threshold’) should also be eligible. Under current NOGG guidelines, based on age-dependent probability thresholds, inequalities in access to therapy arise especially at older ages (≥70 years) depending on the presence or absence of a prior fracture. An alternative threshold using a hybrid model reduces this disparity.
The use of FRAX (fixed or age-dependent thresholds) as the gateway to assessment identifies individuals at high risk more effectively than the use of BMD. However, the setting of intervention thresholds needs to be country-specific.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
American Association of Clinical Endocrinologists
American College of Rheumatology
Area under the receiver operating characteristic (ROC) curve
Bone mineral density
Body mass index
Canadian Association of Radiologists and Osteoporosis Canada
Clinical risk factor
Dual-energy X-ray absorptiometry
European Calcified Tissue Society
European Federation of Pharmaceutical Industry Associations
European Society for Clinical and Economic Aspects of Osteoporosis
WHO fracture risk assessment tool.
Hungarian Society for Osteoporosis and Osteoarthrology
International Osteoporosis Foundation
International Society of Clinical Densitometry
Japanese Society for Bone and Mineral Research
Major osteoporotic fracture
National Clinical Guideline Centre
National Clinical Guideline Centre
National Institute for health and Clinical Excellence
Number Needed to FRAX
Number needed to scan
National Osteoporosis Foundation, US
National Osteoporosis Foundation of South Africa
National Osteoporosis Guideline Group, UK
Net reclassification improvement (I)
Osteoporosis Self-Assessment Tool
Kuopio Osteoporosis Risk Factor and Prevention - study
US Preventive Services Task Force
Quality-adjusted life year
Quality-adjusted life year
A fracture risk assessment tool
Royal College of Physicians, London
Receiver operating characteristics
Screening of older women for prevention of fracture - study
Simple Calculated Osteoporosis Risk Estimation Tool
Scottish Intercollegiate Guidelines Network
Società Italiana dell'Osteoporosi, del Metabolismo Minerale e delle Malattie dello Scheletro
Trabecular bone score
The Health Improvement Network
The number of SD units that BMD differs from the young healthy reference population
World Health Organization
Young adult mean values for BMD
Johnell O, Kanis JA (2006) An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 17:1726–1733
Hernlund E, Svedbom A, Ivergård M et al (2013) Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos 8:136
Kanis JA, Borgström F, Compston J et al (2013) SCOPE: a scorecard for osteoporosis in Europe. Arch Osteoporos 8:144
Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE (2004) Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporos Int 15:767–778
Kanis JA (2002) Diagnosis of osteoporosis and assessment of fracture risk. Lancet 359:1929–1936
Hui SL, Slemenda CW, Johnston CC Jr (1988) Age and bone mass as predictors of fracture in a prospective study. J Clin Invest 81:1804–1809
Kanis JA, Johnell O, Oden A, Dawson A, De Laet C, Jonsson B (2001) Ten year probabilities of osteoporotic fractures according to BMD and diagnostic thresholds. Osteoporos Int 12:989–995
Kanis JA, on behalf of the World Health Organization Scientific Group (2007) Assessment of osteoporosis at the primary health-care level. Technical Report. World Health Organization Collaborating Centre for Metabolic Bone Diseases, University of Sheffield. Accessed https://www.shef.ac.uk/FRAX/reference.aspx 14 July 2015
Hippisley-Cox J, Coupland C (2012) Derivation and validation of updated QFracture algorithm to predict risk of osteoporotic fracture in primary care in the United Kingdom: prospective open cohort study. BMJ 344:e3427. doi:10.1136/bmj.e3427
Nguyen ND, Frost SA, Center JR, Eisman JA, Nguyen TV (2008) Development of prognostic nomograms for individualizing 5-year and 10-year fracture risks. Osteoporos Int 19:1431–1444
National Institute for Health and Care Excellence (2014) NICE clinical guideline 146. Osteoporosis: assessing the risk of fragility fracture. London, UK. https://www.nice.org.uk/guidance/cg146, Accessed18 May 2015
Kanis JA, Compston J, Cooper C et al (2016) SIGN guidelines for Scotland. BMD vs. FRAX vs. QFracture. Calcif Tissue Int 98:417–425
Collins GS, Mallett S, Altman DG (2011) Predicting risk of osteoporotic and hip fracture in the United Kingdom: prospective independent and external validation of QFractureScores. BMJ 342:d3651
Kanis JA, Oden A, Johnell O, Johansson H, De Laet C, Brown J 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
Kanis JA, McCloskey E, Johansson H, Oden A, Leslie WD (2012) FRAX with and without BMD. Calcif Tissue Int 90:1–13
Kanis JA, Johnell O (2005) Requirements for DXA for the management of osteoporosis in Europe. Osteoporos Int 16:229–238
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
Kanis JA, Hans D, Cooper C et al (2011) Interpretation and use of FRAX in clinical practice. Osteoporos Int 22:2395–2411
Middleton RG, Shabani F, Uzoigwe CE, Shoaib A, Moqsith M, Venkatesan M (2012) FRAX and the assessment of the risk of developing a fragility fracture. J Bone Joint Surg 94B:1313–1320
Kanis JA, Johansson H, Oden A, McCloskey EV (2011) Guidance for the adjustment of FRAX according to the dose of glucocorticoids. Osteoporos Int 22:809–816
Leslie WD, Lix LM, Johansson H, Oden A, McLoskey EV, Kanis JA, for the Manitoba Bone Density Program (2011) Spine-hip discordance and fracture risk assessment: a physician-friendly FRAX enhancement. Osteoporos Int 22:839–847
Johansson H, Kanis JA, Odén A et al (2014) Impact of femoral neck and lumbar spine BMD discordances on FRAX probabilities in women: a meta-analysis of international cohorts. Calcif Tissue Int 95:428–435
Leslie WD, Johansson H, Kanis JA, Lamy O, Oden A, McCloskey EV, Hans D (2014) Lumbar spine texture enhances ten-year fracture probability assessment. Osteoporos Int 25:2271–2277
McCloskey EV, Odén A, Harvey NC et al (2015) Adjusting fracture probability by trabecular bone score. Calcif Tissue Int 96:500–509
McCloskey EV, Odén A, Harvey NC et al (2016) A meta-analysis of trabecular bone score in fracture risk prediction and its dependence on FRAX. J Bone Miner Res 31:940–948
Leslie WD, Lix LM, Morin SN et al (2015) Adjusting hip fracture probability in men and women using hip axis length: the Manitoba bone density database. J Clin Densitom. doi:10.1016/j.jocd.2015.07.004
Masud T, Binkley N, Boonen S, Hannan MT, FRAX® Position Development Conference Members (2011) Official Positions for FRAX® clinical regarding falls and frailty: can falls and frailty be used in FRAX®? From Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX®. J Clin Densitom 14:194–204
Kanis JA, McCloskey EV, Johansson H, Cooper C, Rizzoli R, Reginster J-Y, on behalf of the Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) and the Committee of Scientific Advisors of the International Osteoporosis Foundation ( IOF) (2013) European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 24:23–57
Papaioannou A, Morin S, Cheung AM et al (2010) (2010) Clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ 182:1864–1873
Dawson-Hughes B, National Osteoporosis Foundation Guide Committee (2008) A revised clinician’s guide to the prevention and treatment of osteoporosis. J Clin Endocrinol Metab 93:2463–2465
Orimo H, Nakamura T, Hosoi T et al (2012) Japanese 2011 guidelines for prevention and treatment of osteoporosis—executive summary. Arch Osteoporos 7:3–20
Scottish Intercollegiate Guidelines Network (SIGN) (2015) Management of osteoporosis and the prevention of fragility fractures. Edinburgh: SIGN; 2015. (SIGN publication no. 142). [March 2015]. Available from URL: http://www.sign.ac.uk accessed 11 May 2015
Schurman L, Bagur A, Claus-Hemberg H, Messina OD et al (2013) Guias 2012 para el diagnostico, la prevencion y el tratamiento de la osteoporosis. Medicina (Buenos Aires) 73:55–74
Wu CH, McCloskey EV, Lee JK et al (2014) Consensus of official position of IOF/ISCD FRAX initiatives in Asia-Pacific region. J Clin Densitom 17:150–155
Pereira RM, Carvalho JF, Paula AP et al (2012) Guidelines for the prevention and treatment of glucocorticoid-induced osteoporosis. Rev Bras Reumatol 52:580–593, English, Portuguese
Borissova A-M, Zacharieva S, Boyanov M et al (2013) Recommendations for good clinical practice in osteoporosis. http://www.iofbonehealth.org/guideline-references#ref_42 Accessed 22 Oct 2015
Fouda MA, Khan AA, Sultan MS, Rios LP, McAssey K, Armstrong D (2012) Evaluation and management of skeletal health in celiac disease: position statement. Can J Gastroenterol 26:819–829
Zhang Z, Gao B, Liu Z (2012) Fracture risk assessment tool (FRAX) for osteoporosis diagnosis and treatment. Chin J Osteoporos 18:589–595
Curković B, Grazio S, Babić-Naglić D, Anić B, Vlak T, Hanih M (2008) Recommendations of the Croatian Society for Rheumatology for prevention, diagnostics and treatment of post-menopausal osteoporosis. Reumatizam 55:26–30, Croatian
Coleman R, Body JJ, Aapro M, Hadji P, Herrstedt J, on behalf of the ESMO Guidelines Working Group (2014) Bone health in cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol 25(suppl 3):124–137
Brincat M, Calleja-Agius J, Erel CT et al (2011) EMAS position statement: bone densitometry screening for osteoporosis. Maturitas 68:98–101
Duru N, van der Goes MC, Jacobs JW et al (2013) EULAR evidence-based and consensus-based recommendations on the management of medium to high-dose glucocorticoid therapy in rheumatic diseases. Ann Rheum Dis 72:1905–1913
Cortet B, Lartigau E, Caty A et al (2012) Androgen deprivation therapy for prostate cancer and osteoporotic risk. Progres En Urologie 22:S31–S38
Dachverband Osteologie e.V (2011) DVO guideline 2009 for prevention, diagnosis and therapy of osteoporosis in adults. Osteologie 20:55–74, http://www.schattauer.de/en/magazine/subject-areas/journals-a-z/osteology/contents/archive/issue/special (Accessed 19 May 2012)
Osteoporosis Society of Hong Kong (2013) OSHK guideline for clinical management of postmenopausal osteoporosis in Hong Kong. Hong Kong Med J 19(suppl 2):3–40
Meeta, Harinarayan CV, Marwah R, Sahay R, Kalra S, Babhulkar S (2013) Clinical practice guidelines on postmenopausal osteoporosis: an executive summary and recommendations. J Midlife Health 4:107–126. doi:10.4103/0976-7800.115293
Lewiecki EM, Compston JE, Miller PD et al (2011) Official Positions for FRAX® bone mineral density and FRAX® simplification. From Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX®. J Clin Densitom 14:226–236
Irish Osteoporosis Society (2011) Osteoporosis guidelines for health professionals. Pp1-78. Accessed 14 Oct 2015 www.irishosteoporosis.ie
Adami S, Bertoldo F, Brandi ML (2009) Linee guida per la diagnosi, prevenzione e terapia dell’osteoporosi [Guidelines for the diagnosis, prevention and treatment of osteoporosis. Reumatismo 61:260–284
Maalouf G, Bachour F, Issa M et al (2012) Guidelines for fragility fracture in Lebanon. J Med Liban 60:153–158
Sociedad Iberoamericana de Osteología y Metabolismo Mineral [Iberoamerican Society of Osteology and Mineral Metabolism] (2009) Osteoporosis: prevention, diagnosis, and treatment. http://www.iofbonehealth.org/sites/default/files/PDFs/National%20Guidelines/SIBOMMConsensus-2009-english.pdf Accessed 3 Nov 2015
Latvian Osteoporosis and Metabolic Diseases Association (2012) Osteporosis Clinical Guidelines [Osteoporozes klīniskās vadlīnijas]. Nacionālais veselības dienests. Accessed Jan 2013 http://www.vmnvd.gov.lv/lv/420-kliniskas-vadlinijas/klinisko-vadliniju-datu-baze/registretas-2012gada
Conseil Scientifique, Domaine de la Santé, Analyses de laboratoire (2010) Ostéoporose. Accessed 22 October 2015 http://www.conseil-scientifique.lu/index.php?id=84
Peña-Ríos DH, Cisneros-Dreinhofer FA, del Pilar De la Peña-Rodríguez M et al (2015) Consenso de diagnóstico y tratamiento de la osteoporosis en la mujer posmenopáusica mexicana [Consensus for diagnosis and treatment in Mexican women with postmenopausal osteoporosis]. Med Int Méx 31:596–610
Dutch Institute for Healthcare Improvement (CBO) (2011) Richtlijn Osteoporose en fractuurpreventie, derde herziening. CBO, Utrecht
Romanian Ministry of Health (2010) Guidelines for the diagnosis and treatment of postmenopausal osteoporosis. Order number 1322/2010. (www.ms.ro). Accessed 13 March 2015
Czerwiński E, Badurski J, Lorenc R, Osieleniec J (2010) Guidelines on the diagnosis of osteoporosis and assessment of fracture risk in Poland. Ortop Traumatol Rehabil 12(2):194–200, English, [Polish]
Al-Saleh Y, Sulimani R, Sabico S et al (2015) Guidelines for osteoporosis in Saudi Arabia: recommendations from the Saudi Osteoporosis Society. Ann Saudi Med 35:1–12
International Osteoporosis Foundation guideline references, Slovakia http://www.iofbonehealth.org/guideline-references#ref_27 Accessed 22 Oct 2015
Ministry of Health (2010) Osteoporosis: Ministry of Health Practice Guidelines. Ministry of Health, Singapore
Rabar S, Lau R, O’Flynn N, Li L, Barry P, on behalf of the Guideline Development Group (2012) Risk assessment of fragility fractures: summary of NICE guidance. BMJ 345:e3698
American Association of Clinical Endocrinologists (2010) Medial guidelines for clinical practice for the diagnosis and treatment of postmenopausal osteoporosis. Endocr Pract 16(suppl 3):1–37
Tosi LL, Dell RM (2012) AAOS. Challenging orthopaedics to reduce osteoporotic hip fractures, 2012. http://www.aaos.org/news/aaosnow/may09/research5.asp (Accessed 6 Nov 2015).
Qaseem A, Snow V, Shekelle P, Hopkins R Jr, Forciea MA, Owens DK (2008) Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Pharmacologic treatment of low bone density or osteoporosis to prevent fractures: a clinical practice guideline from the American College of Physicians. Ann Intern Med 149:404–415
Lim LS, Hoeksma LJ, Sherin K (2009) Screening for osteoporosis in the adult US population: ACPM position statement on preventive practice. Am J Prev Med 36:366–375
Kanis JA (2013) Commentary on guidelines on postmenopausal osteoporosis—Indian Menopause Society. J Midlife Health 4:129–131, Available from: http://www.jmidlifehealth.org/text.asp?2013/4/2/129/
National Osteoporosis Foundation (2015) Clinician’s guide to prevention and treatment of osteoporosis. http://nof.org/hcp/resources/913 Accessed 9 Feb 2015
Socialstyrelsen (2010) Nationella riktlinjer för rörelseorganens sjukdomar 2010—stöd för styrning och ledning. Preliminär version. Artikelnr 2010-11-15. Published at www.socialstyrelsen.se Accessed 3 Nov 2015
Mazokopakis EE, Starakis IK (2011) Recommendations for diagnosis and management of osteoporosis in COPD men. ISRN Rheumatol 2011:901416. doi:10.5402/2011/901416
Arznei & Vernunft (2010) Osteoporose. Knochenbruch- Krankheit. Pharmig, Verband der pharmazeutischen Industrie Österreichs
Body J-J (2012) Aromatase inhibitors-induced bone loss in early breast cancer. Bone Key Rep 1:201. doi:10.1038/bonekey.2012.201
British Columbia Medical Association (2012) Osteoporosis: diagnosis, treatment and fracture prevention. British Columbia Medical Association and British Columbia Ministry of health
Khan A, Fortier M (2014) Osteoporosis in menopause. J Obstet Gynaecol Can 36(9):S1–S15
Zhang Z, Ou Y, Sheng Z, Liao E (2014) How to decide intervention thresholds based on FRAX in central south Chinese postmenopausal women. Endocrine 45:195–197
Stepan J (2009) Algorithm of treatment of glucocorticoid induced osteoporosis—search for criteria. Vnitr Lek 55:448–454
Rizzoli R, Body JJ, DeCensi A, Reginster JY, Piscitelli P, Brandi ML (2012) Guidance for the prevention of bone loss and fractures in postmenopausal women treated with aromatase inhibitors for breast cancer: an ESCEO position paper. Osteoporos Int 23:2567–2576, and erratum Osteoporos Int 23: 2577
Koski AM (2013) Glukokortikoidin aiheuttaman osteoporoosin hoitokaavio. http://www.kaypahoito.fi/web/kh/suositukset/suositus?id=ima02292 Accessed 4 Nov 2015
Makras P, Paiopoulos G, Lyritis GP (2012) 2011 Guidelines for the diagnosis and treatment of osteoporosis in Greece. J Musculoskelet Neuronal Interact 12:38–42
Makras P, Athanasakis K, Boubouchairopoulou N et al (2015) Cost-effective osteoporosis treatment thresholds in Greece. Osteoporos Int 26:1949–1957
Cheung E, Kung AWC, Tan KCB (2014) Outcomes of applying the NOF, NOGG and Taiwanese guidelines to a cohort of Chinese early postmenopausal women. Clin Endocrinol 80:200–207
Lakatos P, Szekeres L, Takács I et al (2011) Diagnostic and therapeutic guidelines for the age-related and glucocorticoid-induced osteoporosis—2011, Hungary. Magyar Reumatol 1:28–33, Hungarian
Nakatoah S, Takemaru Y (2013) Application of the fracture risk assessment tool (FRAX®) and determination of suitable cut-off values during primary screening I specific health check-ups in Japan. J Bone Miner Metab 31:674–680
Chakhtoura M, Baddoura R , El-Hajj Fuleihan G (2013) Lebanese FRAX-based osteoporosis guidelines. http://www.osteos.org.lb/admin/uploads/Full%20document.pdf Accessed 19 Oct 2015
Malaysian Osteoporosis Society (2012) Clinical guidance on management of osteoporosis. http://www.iofbonehealth.org/sites/default/files/PDFs/National%20Guidelines/Malaysia_CG_Mgmt_Osteoporosis_2012-0912-final.pdf Accessed 14 Oct 2015
Yeap SS, Hew FL, Lee JK et al (2013) The Malaysian clinical guidance on the management of postmenopausal osteoporosis, 2012: a summary. Int J Rheum Dis 16:30–40
Cymet-Ramírez J, Cisneros-Dreinhofer FA, Alvarez-Martínez MM et al (2011) Diagnosis and treatment of osteoporosis. Position of the Mexican College of Orthopedics and Traumatology. Acta Ortop Mex 25:303–312, Spanish
Li-Yu J, Perez EC, Cañete A, Bonifacio L et al (2011) Clinical Practice Guidelines Task Force Committee on Osteoporosis. Consensus statements on osteoporosis diagnosis, prevention, and management in the Philippines. Int J Rheum Dis 14:223–238
Badurski JE, Kanis JA, Johansson H et al (2011) The application of FRAX (R) to determine intervention thresholds in osteoporosis treatment in Poland. Pol Arch Med Wewn 121:148–154
Lorenc R, Głuszko P, Karczmarewicz E et al (2011) Polish recommendations on the diagnosis and treatment of osteoporosis. Medycyna Praktyczna(Reumatologia) Special Edition 1/2011 [Polish]
Badurski J, Jeziernicka E, Dobrenko A et al (2011) The characteristics of osteoporotic fractures in the region of Bialystok (BOS-2). The application of the WHO algorithm, FRAX (R) BMI and FRAX (R) BMD assessment tools to determine patients for intervention. Endokrynol Pol 62:290–298
Gluszko P, Lorenc RS, Karczmarewicz E, Misiorowski W, Jaworski M (2014) Polish guidelines for the diagnosis and management of osteoporosis: a review of 2013 update. Pol Arch Med Wewn 124:255–263
Goncalves MJ, Rodrigues AM, Canhao H, Fonseca JE (2013) Osteoporosis: from bone biology to individual treatment decision. Acta Med Port 26:445–455
Amin TT, Al Owaifeer A, Al-Hashim H et al (2013) Osteoporosis among older Saudis: risk of fractures and unmet needs. Arch Osteoporos 8:118
Niemethova E, Killinger Z, Payer J (2013) Fracture risk prediction with FRAX in Slovak postmenopausal women. Cent Eur J Med 8:571–586
Kocjan T, Prezelj J, Pfeifer M, Sever MJ, Cokolic M, Zavratnik A (2013) Guidelines for the detection and treatment of osteoporosis. Zdrav Vestn 82:207–217
International Osteoporosis Foundation guideline references, Slovenia http://www.iofbonehealth.org/guideline-references#ref_38 Accessed 22 Oct 2015
Hough S, Ascott-Evans B-H, Brown SL et al for the National Osteoporosis Foundation of South Africa (NOFSA) (2010) NOFSA guideline for the diagnosis and management of osteoporosis. Available online at: www.jemdsa.co.za and www.osteoporosis.org.za Accessed 22 Oct 2015
Kim JW, Jeon YJ, Baek DH, Kim TN, Chang JS (2014) Percentage of the population at high risk of osteoporotic fracture in South Korea: analysis of the 2010 Fifth Korean National Health and Nutrition Examination survey data. Osteoporos Int 25:1313–1319
Pérez Edo L, Alonso Ruiz A, Roig Vilaseca D, Spanish Society of Rheumatology et al (2011) 2011 Up-date of the consensus statement of the Spanish Society of Rheumatology on osteoporosis. Reumatol Clin 7:357–379, Spanish
Etxebarria-Foronda I, Caeiro-Rey JR, Larrainzar-Garijo R et al (2015) Guía SECOT-GEIOS en osteoporosis y fractura por fragilidad. Actualización. Rev Esp Cir Ortop Traumatol 59:373–393
García R, Jódar Gimeno E, García Martín A et al (2012) Clinical practice guidelines for evaluation and treatment of osteoporosis associated to endocrine and nutritional conditions. Bone Metabolism Working Group of the Spanish Society of Endocrinology. Endocrinol Nutr 59:174–196, Erratum in: Endocrinol Nutr. 2012 59: 469
Lekamwasam S (2013) Sri Lankan FRAX model and country-specific intervention thresholds. Arch Osteoporos 8:148
Johansson H, Kanis JA, Ljunggren O, Strom O, Svensson O, Mellstrom D (2011) FRAX—model for 10-year fracture risk assessment. Support in the treatment of osteoporosis, according to preliminary Swedish guidelines. Lakartidningen 108:336–339
Lippuner K, Johansson H, Borgström F et al (2012) Cost-effective intervention thresholds against osteoporotic fractures based on FRAX® in Switzerland. Osteoporos Int 23:2579–2589
Taiwanese Osteoporosis Association (2012) Taiwanese Guidelines for the Prevention and Treatment of Osteoporosis http://www.iofbonehealth.org/sites/default/files/PDFs/National%20Guidelines/Taiwanese_guidelines_prevention_treatment_osteoporosis.pdf Accessed 22 Oct 2015
Pongchaiyakul C, Leerapun T, Wongsiri S, Songpattanasilp T, Taechakraichana N (2012) Value and validation of RCOST and TOPF clinical practice guideline for osteoporosis treatment. J Med Assoc Thai 95:1528–1535
Davis S, Martyn-St James M, Sanderson J, et al (2015) Bisphosphonates for preventing osteoporotic fragility fractures (including a partial update of NICE technology appraisal guidance 160 and 161).Technology Assessment Report commissioned by the NIHR HTA Programme on behalf of the National Institute for Health and Care Excellence. Produced by ScHARR, The University of Sheffield
McCloskey E, Kanis JA, Johansson H et al (2015) FRAX-based assessment and intervention thresholds—an exploration of thresholds in women aged 50 years and older in the UK. Osteoporos Int 26:2091–2099
Lyell V, Henderson E, Devine M, Gregson C (2015) Assessment and management of fracture risk in patients with Parkinson’s disease. Age Ageing 44:34–41
Cosman F, de Beur SJ, LeBoff MS et al (2014) Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int 25:2359–2381
Nelson HD, Haney EM, Chou R, Dana T, Fu R, Bougatsos C (2010) Screening for osteoporosis: systematic review to update the 2002 US Preventive Services Task Force Recommendation. Evidence Syntheses No. 77. AHRQ Publication No. 10-05145-EF-1.
Grossman JM, Gordon R, Ranganath VK et al (2010) American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Arth Care Res 62:1515–1526
Watts NB, Adler RA, Bilezikian JP et al (2012) Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 97:1802–1822
Scillitani A, Mazziotti G, Di Somma C et al (2014) Treatment of skeletal impairment in patients with endogenous hypercortisolism: when and how? Osteoporos Int 25:441–446
American College of Obstetricians and Gynecologists (ACOG). Osteoporosis. Washington (DC): American College of Obstetricians and Gynecologists (AC OG); 2012 Sep. 17. p. (ACOG practice bulletin; no. 129)
North American Menopause Society (NAMS) (2010) Management of osteoporosis in postmenopausal women: 2010 position statement of The North American Menopause Society. Menopause 17:25–54
Sweet MG, Sweet JM, Jeremiah MP, Galaska SS (2008) Diagnosis and treatment of osteoporosis. Am Fam Physician 79:193–200
Adler RA, Hastings FW, Petkov VI (2010) Treatment thresholds for osteoporosis in men on androgen deprivation therapy: T-score versus FRAX. Osteoporos Int 21:647–653
Gralow JR, Biermann JS, Farooki A et al (2009) NCCN task force report: bone health in cancer care. J Natl Compr Cancer Netw 7:S1–S32
Jeremiah MP, Unwin BK, Greenawald MH, Casiano VE (2015) Diagnosis and management of osteoporosis. Am Fam Physician 92:261–268
Institute for Clinical Systems Improvement (2013) Diagnosis and treatment of osteoporosis. http://www.isci.org/guidelines_more Accessed 29 Jan 2016
Florence R, Allen S, Benedict L et al (2013) Diagnosis and treatment of osteoporosis. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_musculoskeletal_guidelines/osteoporosis/ Accessed 1 November 2015
Tosteson AN, Melton LJ 3rd, Dawson-Hughes B et al (2008) Cost-effective osteoporosis treatment thresholds: the United States perspective. Osteoporos Int 19:437–447
Berry SD, Kiel DP, Donaldson MG et al (2010) Application of the National Osteoporosis Foundation Guidelines to postmenopausal women and men: the Framingham Osteoporosis Study. Osteoporos Int 21:53–60
Dawson-Hughes B, Looker AC, Tosteson AN, Johansson H, Kanis JA, Melton LJ 3rd (2010) The potential impact of new National Osteoporosis Foundation guidance on treatment patterns. Osteoporos Int 21:41–52
Crandall CJ, Larson J, Gourlay M et al (2014) Osteoporosis screening in postmenopausal women 50–64 years-old: Comparison of U.S. Preventive Services Task Force strategy and two traditional strategies in the Women’s Health Initiative. J Bone Miner Res 29:1661–1666
Kanis JA, Harvey N, McCloskey EV (2014) Pre-screening young postmenopausal women for BMD testing. BoneKEy Reports 3, Article number: 544 doi:10.1038/bonekey.39, Published online 11 June 2014
Lydick E, Cook K, Turpin J, Melton M, Stine R, Byrnes C (1998) Development and validation of a simple questionnaire to facilitate identification of women likely to have low bone density. Am J Manag Care 4:37–48
Koh LK, Sedrine WB, Torralba TP et al (2001) A simple tool to identify Asian women at increased risk of osteoporosis. Osteoporos Int 12:699–705
Bansal S, Pecina JL, Merry SP et al (2015) US Preventative Services Task Force FRAX threshold has a low sensitivity to detect osteoporosis in women ages 50–64 years. Osteoporos Int 26:1429–1433
National Osteoporosis Foundation (NOF) (2008) Clinician’s Guide to prevention and treatment of osteoporosis. DC National Osteoporosis Foundation, Washington
van Staa TP, Leufkens HG, Abenhaim L, Zhang B, Cooper C (2000) Oral corticosteroids and fracture risk: relationship to daily and cumulative doses. Rheumatol (Oxford) 39:1383–1389
Orimo H, Hayashi Y, Fukunaga M et al (2001) Diagnostic criteria for primary osteoporosis: year 2000 revision. Jap J Bone Miner Metab 19:331–337
Fujiwara S, Nakamura T, Orimo H (2008) Development and application of a Japanese model of the WHO fracture risk assessment tool (FRAX). Osteoporos Int 19:429–435
Kanis JA, Delmas P, Burckhardt P, Cooper C, Torgerson D (1997) Guidelines for diagnosis and management of osteoporosis. Osteoporos Int 7:390–406
Royal College of Physicians (1999) Osteoporosis: clinical guidelines for the prevention and treatment. RCP, London
Hwang J, Chan D, Chen J, Cheng T, Wu C, Soong Y et al (2013) Clinical practice guidelines for the prevention and treatment of osteoporosis in Taiwan: summary. J Bone Miner Metab 31:1–7
Compston J, Bowring C, Cooper A et al (2013) Diagnosis and management of osteoporosis in postmenopausal women and older men in the UK: National Osteoporosis Guideline Group (NOGG) update 2013. Maturitas 75:392–396
Kanis JA, McCloskey EV, Johansson H, Strom O, Borgstrom F (2009) Oden A and the National Osteoporosis Guideline Group (2008) Case finding for the management of osteoporosis with FRAX®—assessment and intervention thresholds for the UK. Osteoporos Int 1395:499–1408, Erratum in Osteoporos Int 2009;20:499–502
Compston J, Cooper A, Cooper C 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
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
Kanis JA, Stevenson M, McCloskey EV, Davis S, Lloyd-Jones M (2007) Glucocorticoid-induced osteoporosis: a systematic review and cost-utility analysis. Health Technol Assess 11:1–256
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
Kyriakos G, Vidal-Casariego A, Fernandez-Martinez MN et al (2015) Impact of the NOGG and NOF guidelines on the indication of bone mineral density in routine clinical practice. J Clin Densitom 18:533–538
Chen JS, Simpson JM, Blyth FM, March LM (2014) Managing osteoporosis with FRAX (R) in Australia: proposed new treatment thresholds from the 45 &Up Study cohort. Bone 69:148–153
Johansson H, Kanis JA, McCloskey EV et al (2011) A FRAX (R) model for the assessment of fracture probability in Belgium. Osteoporos Int 22:453–461
Zerbini CAF, Szejnfeld VL, Abergaria BH, McCloskey EV, Johansson H, Kanis JA (2015) Incidence of hip fracture in Brazil and the development of a FRAX model. Arch Osteoporos 10:224
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
Niskanen L, Kettunen J, Koski A-M et al for the Finnish Medical Society Duodecim, Finnish Endocrine Society and Finnish Gynaecological Association (National) (2014) Osteoporosis. Current care guidelines. Suomalaisen Lääkäriseuran Duodecimin, Suomen Endokrinologiyhdistyksen ja Suomen Gynekologiyhdistyksen asettama työryhmä (2014) Osteoporoosi. http://www.terveysportti.fi/xmedia/hoi/hoi24065.pdf Accessed 26 Oct 2015
Briot K, Cortet B, Thomas T et al (2012) 2010 update of French guidelines for the pharmacological treatment of postmenopausal osteoporosis. Joint Bone Spine 79:304–313
McGowan B, Kanis JA, Johansson H, Silke C, Whelan B (2013) Development and use of FRAX in the management of osteoporosis in Ireland. Arch Osteoporos 8:146. doi:10.1007/s11657-013-0146-z
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
Lesnyak O, Ershova O, Belova K et al (2012) Epidemiology of fracture in the Russian Federation and the development of a FRAX model. Arch Osteoporos 7:67–73. doi:10.1007/s11657-012-0082-3
Russian Association on Osteoporosis (2013) http://www.osteoporoz.ru/content/view/891/113/ Accessed 22 Oct 2015
International Osteoporosis Foundation (2012) Ministry of Health official officially launches FRAX model in Sri Lanka http://www.iofbonehealth.org/ministry-health-official-officially-launches-frax-model-sri-lanka Accessed 21 Oct 2015
Association Suisse Contre l’Ostéoporose (2015) www.svgo.ch Accessed 18 Oct 2015
Nottinghamshire Osteoporosis Guidelines 2014 http://www.nottsapc.nhs.uk/attachments/article/3/osteoporosis%20guideline.pdf Accessed 1 Nov 2015
Bruyere O, Fossi M, Zegels D, Leonori L, Hiligsmann M, Neuprez A, Reginster JY (2013) Comparison of the proportion of patients potentially treated with an anti-osteoporotic drug using the current criteria of the Belgian national social security and the new suggested FRAX criteria. Rheumatol Int 33:973–978
National Clinical Guideline Centre (2012) Osteoporosis: fragility fracture risk. Osteoporosis: assessing the risk of fragility fracture. Short clinical guideline—CG146 Evidence and recommendations August 2012. Published by the National Clinical Guideline Centre by the Royal College of Physicians, London
Shepstone L, Lenaghan E, Cooper et al (2012) A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of screening older women for the prevention of fractures: rationale, design and methods for the ‘SCOOP’ Study. Osteoporos Int 23:2507–2515
Strom O, Borgstrom F, Kleman M et al (2010) FRAX and its applications in health economics—cost-effectiveness and intervention thresholds using bazedoxifene in a Swedish setting as an example. Bone 47:430–437
Strom O, Jonsson B, Kanis JA (2013) Intervention thresholds for denosumab in the UK using a FRAX(R)-based cost-effectiveness analysis. Osteoporos Int 24:1491–1502
Michigan Quality Improvement Consortium Guideline (2014) Management and prevention of osteoporosis Michigan quality improvement consortium Accessed 25 Oct 2015
Kanis JA, Adams J, Borgstrom F et al (2008) The cost-effectiveness of alendronate in the management of osteoporosis. Bone 42:4–15
Borgström F, Ström O, Coelho J, Johansson H, Oden A, McCloskey EV, Kanis JA (2010) The cost-effectiveness of risedronate in the UK for the management of osteoporosis using the FRAX. Osteoporos Int 21:495–505
Jonsson B, Strom O, Eisman JA et al (2011) Cost-effectiveness of denosumab for the treatment of postmenopausal osteoporosis. Osteoporos Int 22:967–982
Ivergard M, Strom O, Borgstrom F, Burge RT, Tosteson AN, Kanis J (2010) Identifying cost-effective treatment with raloxifene in postmenopausal women using risk algorithms for fractures and invasive breast cancer. Bone 47:966–974
Borgstrom F, Strom O, Coelho J et al (2010) The cost-effectiveness of strontium ranelate in the UK for the management of osteoporosis. Osteoporos Int 21:339–349
Borgstrom F, Strom O, Kleman M et al (2010) Cost-effectiveness of bazedoxifene incorporating the FRAX(R) algorithm in a European perspective. Osteoporos Int 22:955–965
Azagra R, Roca G, Martin-Sanchez et al (2015) FRAX thresholds to identify people with high or low risk of osteoporotic fracture in Spanish female population. Med Clin (Barc) 144:1–8
National Institute for Health and Clinical Excellence (2010) Denosumab for the prevention of osteoporotic fractures in postmenopausal women. Technology appraisal 204 http://guidance.nice.org.uk/TA204 Accessed 24 May 2011
National Institute for Health and Clinical Excellence (2011a) Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women. Technology appraisal TA160. http://guidance.nice.org.uk/TA160 Accessed 24 May 2011
National Institute for Health and Clinical Excellence (2011b) Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. Technology appraisal TA161. http://egap.evidence.nhs.uk/TA161 Accessed 24 May 2011
Kanis JA, McCloskey E, Jönsson B, Cooper A, Ström O, Borgström F (2010) An evaluation of the NICE guidance for the prevention of osteoporotic fragility fractures in postmenopausal women. Arch Osteoporos 5:19–48
Zethraeus N, Borgstrom F, Strom O, Kanis JA, Jonsson B (2007) Cost-effectiveness of the treatment and prevention of osteoporosis—a review of the literature and a reference model. Osteoporos Int 18:9–23
Hippisley-Cox J, Coupland C (2009) Predicting risk of osteoporotic fracture in men and women in England and Wales: prospective derivation and validation of QFractures scores. Br Med J 339:b4229
Chen P, Krege JH, Adachi JD et al (2009) Vertebral fracture status and the World Health Organization risk factors for predicting osteoporotic fracture risk. J Bone Miner 24:495–502
Sornay-Rendu E, Munoz F, Delmas PD, Chapurlat RD (2010) The FRAX® tool in French women: how well does it describe the real incidence of fracture in the OFELY cohort. J Bone Miner Res 25:2101–2107
Bolland MJ, Siu AT, Mason BH et al (2011) Evaluation of the FRAX and Garvan fracture risk calculators in older women. J Bone Miner Res 26:420–427
Ensrud KE, Lui LY, Taylor BC et al (2009) A comparison of prediction models for fractures in older women: is more better? Arch Intern Med 169:2087–2094
Tremollieres FA, Pouilles JM, Drewniak N, Laparra J, Ribot CA, Dargent-Molina P (2010) Fracture risk prediction using BMD and clinical risk factors in early postmenopausal women: sensitivity of the WHO FRAX tool. J Bone Miner Res 25:1002–1009
Donaldson MG, Palermo L, Schousboe JT, Ensrud KE, Hochberg MC, Cummings SR (2009) FRAX and risk of vertebral fractures: the fracture intervention trial. J Bone Miner Res 24:1793–1799
Hillier TA, Cauley JA, Rizzo JH (2011) The WHO absolute fracture risk models (FRAX): do clinical risk factors improve fracture prediction in older women without osteoporosis? J Bone Miner Res 26:1774–1782
Pluskiewicz W, Adamczyk P, Franek E et al (2010) Ten-year probability of osteoporotic fracture in 2012 Polish women assessed by FRAX and nomogram by Nguyen et al.—conformity between methods and their clinical utility. Bone 46:1661–1667
Tamaki J, Iki M, Kadowaki E, Sato Y et al (2011) The clinical utility of FRAX to discriminate fracture status in men and women with chronic kidney disease. Osteoporos Int 25:71–76
Azagra R, Roca G, Encabo G et al (2012) FRAX® tool, the WHO algorithm to predict osteoporotic fractures: the first analysis of its discriminative and predictive ability in the Spanish FRIDEX cohort. BMC Musculoskelet Disord 13:204. doi:10.1186/1471-2474-13-204
Sandhu SK, Nguyen ND, Center JR, Pocock NA, Eisman JA, Nguyen TV (2010) Prognosis of fracture: evaluation of predictive accuracy of the FRAX™ algorithm and Garvan nomogram. Osteoporos Int 21:863–871
Leslie WD, Lix LM (2014) Comparison between various fracture risk assessment tools. Osteoporos Int 25:1–21
Kanis JA, Oden A, Johansson H, McCloskey E (2012) Pitfalls in the external validation of FRAX. Osteoporos Int 23:423–431
Marques A, Ferreira RJO, Santos E, Loza E, Carmona L, Pereira da Silva JA (2015) The accuracy of osteoporotic fracture risk prediction tools: a systematic review and meta-analysis. Ann Rheum Dis. Downloaded from http://ard.bmj.com/ on 7 Aug 2015
Nayak S, Edwards DL, Saleh AA, Greenspan SL (2015) Systematic review and meta-analysis of the performance of clinical risk assessment instruments for screening for osteoporosis or low bone density. Osteoporos Int 26:1543–1554
Kanis JA, Odén A, Johansson H, McCloskey EV (2013) Pitfalls in the external validation of FRAX: response to Bolland et al. Osteoporos Int 24:391–392
Fraser LA, Langsetmo L, Berger C et al (2011) Fracture prediction and calibration of a Canadian FRAX tool: a population-based report from CaMos. Osteoporos Int 22:829–837
Leslie WD, Lix LM, Johansson H et al (2010) Independent clinical validation of a Canadian FRAX tool: fracture prediction and model calibration. J Bone Miner Res 25:2350–2358
Rubin KH, Abrahamsen B, Hermann AP et al (2011) Fracture risk assessed by fracture risk assessment tool (FRAX) compared with fracture risk derived from population fracture rates. Scand J Public Health 39:312–318
Sund R, Honkanen R, Johansson H, Oden A, McCloskey EV, Kanis JA, Kröger H (2014) Evaluation of the FRAX model for the prediction of hip fractures in Kuopio, Finland. Calcif Tiss Int 95:39–45
Sund R (2007) Utilization of routinely collected administrative data in monitoring of aging-dependent hip fracture incidence. Epidemiol Perspect Innov 4:2
Sund R (2006) Hip fracture incidence in Finland, 1998–2002. Duodecim 122(9):1085–1091
Abrahamsen B, Vestergaard P, Rud B et al (2006) Ten-year absolute risk of osteoporotic fractures according to BMD T score at menopause: the Danish osteoporosis prevention study. J Bone Miner Res 21:796–800
Azagra R, Roca G, Zwart M, Encabo G (2011) Differences in the predictive values of the FRAX (TM) tool between the Spanish and United Kingdom population and considerations about the intervention threshold. Med Clin (Barc) 137(15):713–714
Ettinger B, Ensrud KE, Blackwell T et al (2013) Performance of FRAX in a cohort of community-dwelling, ambulatory older men: the Osteoporotic Fractures in Men (MrOS) study. Osteoporos Int 24:1185–1193
Schwartz AV, Vittinghoff E, Bauer DC et al (2011) Association of BMD and FRAX score with risk of fracture in older adults with type 2 diabetes. JAMA 305:2184–2192
Pressman AR, Lo JC, Chandra M, Ettinger B (2011) Methods for assessing fracture risk prediction models: experience with FRAX in a large integrated healthcare delivery system. J Clin Densitom 14:407–415
Donaldson MG, Cawthon PM, Schousboe JT et al (2011) Novel methods to evaluate fracture risk models. J Bone Miner Res 26:1767–1773
Gullberg B, Johnell O, Kanis JA (1997) World-wide projections for hip fractures. Osteoporos Int 7:407–413
Cooper C, Cole ZA, Holroyd CR, Earl SC, Harvey NC, Dennison EM, the IOF CSA Working Group on Fracture Epidemiology (2011) Secular trends in the incidence of hip and other osteoporotic fractures. Osteoporos Int 22:1277–1288
Kanis JA, Johansson H, Odén A, Dawson-Hughes B, Melton LJ 3rd, McCloskey EV (2010) The effects of a FRAX® revision for the USA. Osteoporos Int 21:35–40
Brennan SL, Quirk SE, Hosking SM et al (2015) Is there an interaction between socioeconomic status and FRAX 10-year fracture probability determined with and without bone density measures? Data from the Geelong Osteoporosis Study of Female Cohort. Calcif Tissue Int 96:138–144
Leslie WD, Lix LM, Johansson H, Oden A, McCloskey E, Kanis J (2012) Does osteoporosis therapy invalidate FRAX for fracture prediction? J Bone Miner Res 27:1243–1251
Johansson H, Odén A, Lorentzon M et al (2015) Is the Swedish FRAX model appropriate for immigrants to Sweden? Osteoporos Int 26:2617–2622
Leslie WD, Berger C, Langsetmo L et al (2011) Construction and validation of a simplified fracture risk assessment tool for Canadian women and men: results from the CaMos and Manitoba cohorts. Osteoporos Int 22:1873–1883
Johansson H, Kanis JA, Oden A, Johnell O, McCloskey E (2009) BMD, clinical risk factors and their combination for hip fracture prevention. Osteoporos Int 20:1675–1682
Yoon J, Kwon S-R, Lim M-J et al (2010) A comparison of three different guidelines for osteoporosis treatment in patients with rheumatoid arthritis in Korea. Korean J Intern Med 25:436–446
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
Leslie W, Morin S, Majumdar S et al (2016) Net reclassification Improvement with FRAX versus a simpler risk assessment system: more is more. J Bone Miner Res 30:S103 (Paper accepted Osteoporos Int, Feb 2016)
Kanis JA, Johansson H, Odén A, McCloskey EV (2012) The distribution of FRAX® based probabilities in women from Japan. J Bone Miner Metab 30:700–705
Borgstrom F, Johnell O, Kanis JA et al (2006) At what hip fracture risk is it cost-effective to treat? International intervention thresholds for the treatment of osteoporosis. Osteoporos Int 17:1459–1471
Oden A, McCloskey EV, Johansson H, Kanis JA (2013) Assessing the impact of osteoporosis on the burden of hip fractures. Calcif Tissue Int 92:42–49
McCloskey EV, Johansson H, Harvey NC, Compston J, Kanis JA (2015) Online linkage of FRAX fracture risk assessment to management guidance is used by clinical practitioners. An analysis of access to National Osteoporosis Guideline Group Guidance in the UK (July 2013-June2014). J Bone Miner Res 30:S290–S291, (Paper accepted Osteoporos Int, June 2016)
Crabtree NJ, Bebbington NA, Chapman DM et al (2010) Impact of UK National Guidelines based on FRAX(R)—comparison with current clinical practice. Clin Endocrinol 73:452–456
Kanis JA, Johansson H, Oden A, Cooper C, McCloskey EV, and the Epidemiology and Quality of Life Working Group of IOF (2013) Worldwide uptake of FRAX. Arch Osteoporos 8:166. doi:10.1007/s11657-013-0166-8
Brennan SL, Leslie WD, Leslie WD, Lix LM et al (2014) FRAX provides robust fracture prediction regardless of socioeconomic status. Osteoporos Int 25:61–69
Kayan K, Johansson H, Oden A et al (2009) Can fall risk be incorporated into fracture risk assessment algorithms: a pilot study of responsiveness to clodronate. Osteoporos Int 20:2055–2061
McClung MR, Geusens P, Miller PD et al (2001) Effect of risedronate on the risk of hip fracture in elderly women. Hip Intervention Program Study Group. N Engl J Med 344:333–340
Harvey NC, Johansson H, Odén A et al (2016) FRAX predicts incident falls in elderly men. Findings from MrOs Sweden. Osteoporos Int 27:267–274
Johansson J, Harvey N, Odén A et al (2015) The predictive value of falls history for incident fracture decreases with time: MrOs Sweden. J Bone Miner Res 30:S424
Cauley JA, El-Hajj Fuleihan G, Luckey MM, FRAX® Position Development Conference Members (2011) Official positions for FRAX clinical regarding international differences. FRAX® International Task Force of the 2010 Joint International Society for Clinical Densitometry & International Osteoporosis Foundation Position Development Conference. J Clin Densitom 14:237–239
van den Bergh JP, van Geel TA, Lems WF, Geusens PP (2010) Assessment of individual fracture risk: FRAX and beyond. Curr Osteoporos Rep 8(3):131–137
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
Leslie WD, Morin S, Lix LM et al (2012) Fracture risk assessment without bone density measurement in routine clinical practice. Osteoporos Int 23:75–85
We are grateful to the University of Southampton and the International Osteoporosis Foundation for their help with the literature searches. The manuscript was appraised by the members of the Committee of Scientific Advisors of the International Osteoporosis Foundation and the National Osteoporosis Guideline Group (UK) and we appreciate their constructive reviews. We are grateful to the International Osteoporosis Foundation and the National Osteoporosis Guideline Group for their endorsement of this paper.
Conflicts of interest
Professor Kanis led the team that developed FRAX as director of the 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 Cooper, Kanis, Harvey and McCloskey are members of the Advisory Board of the National Osteoporosis Guideline Group. Ken E Poole, Neil Gittoes and Sally Hope declare no competing interests with respect to this paper.
Members of the Advisory Board of the National Osteoporosis Guideline Group: Cyrus Cooper, Nicholas Harvey, Eugene McCloskey, Ken E. Poole (Department of Medicine, University of Cambridge, Cambridge, UK); John A. Kanis, Neil Gittoes (Department of Endocrinology, University Hospitals Birmingham and University of Birmingham, Birmingham, UK); Sally Hope (Metabolic Bone Unit/Oxfordshire Osteoporosis Service, Nuffield Orthopaedic Centre, Oxford, UK).
Redundant references from systematic search
Adami S, Bertoldo F, Gatti D, et al. (2013) Treatment thresholds for osteoporosis and reimbursability criteria: perspectives associated with fracture risk-assessment tools. Calcif Tissue Int 93: 195-200.
Aker MB, Abu Taha AS, Zyoud SH, Sawalha AF, Al-Jabi SW, Sweileh WM (2013) Estimation of 10-year probability bone fracture in a selected sample of Palestinian people using fracture risk assessment tool. BMC Musculoskeletal Disorders 2013; 14.
Atik OS (2013) How valid FRAX is in different countries? Eklem Hastaliklari Ve Cerrahisi-Joint Diseases and Related Surgery 24: 63.
Aubry-Rozier B, Stoll D, Krieg M-A, Lamy O, Hans D (2013) What was your fracture risk evaluated by FRAX® the day before your osteoporotic fracture? Clin Rheumatol 32: 219-23.
Becorpi A, Sisti G, Sorbi F, Malosso ERM, Guaschino S (2014) Management options of breast cancer related osteoporosis. Clinical cases in mineral and bone metabolism: the official journal of the Italian Society of Osteoporosis, Mineral Metabolism, and Skeletal Diseases 11: 110-3.
Blake GM, Fogelman I (2010) An update on dual-energy X-ray absorptiometry. Seminars in Nuclear Medicine 40: 62-73.
Bolland MJ, Jackson R, Gamble GD, Grey A (2013) Discrepancies in predicted fracture risk in elderly people. BMJ 346:e8669.
Brennan SL, Leslie WD, Lix LM (2014) Is lower income associated with an increased likelihood of qualification for treatment for osteoporosis in Canadian women? Osteoporos Int 25: 273-9.
Brewer L, Mellon L, Duggan J (2013) Ability of fracture risk assessment tool and National Osteoporosis Guideline Group Guidance to stratify people appropriately before fracture. J Am Geriatr Soc 61: 1633-4.
Bridges M, Ruddick S (2012) Modifying FRAX/NOGG guidelines in rheumatology patients receiving corticosteroids: does it make any difference? Rheumatol 51: 106-7.
Bridges MJ, Ruddick S (2010) Ability of FRAX/NOGG guidelines to identify patients sustaining low trauma fractures. Rheumatol 49: 391-2.
Bridges MJ, Ruddick SA (2012) Do FRAX/NOGG guidelines predict fractures in post-menopausal women with type 2 diabetes? Diabetic Med 2012; 29: 555-6.
Bruyère O, Nicolet D, Compère S et al. (2013) Perception, knowledge, and use by general practitioners of Belgium of a new WHO tool (FRAX) to assess the 10-year probability of fracture. Rheumatol Int 33: 979-83.
Canavan JB, Trivedi PJ, Bailey AN, et al. (209) Fracture risk assessment using DXA and FRAX in patients with celiac disease. Gastroenterol 136: A474-A.
Carlos F, Clark P, Galindo-Suarez RM, Chico-Barba LG (2013) Health care costs of osteopenia, osteoporosis, and fragility fractures in Mexico. Arch Osteoporos 8: 125.
Chakhtoura M, Cheung AM, Kanis JA, et al. (2014) FRAX-based guidelines: is a universal model appropriate ? Osteoporos Int 25: S121-S2.
Chapurlat R (2012) [Osteoporosis without fracture: when do we treat?]. La Revue du Praticien 62: 199-201.
Chinese Medical Association of osteoporosis and bone mineral disease branch (2011) Primary osteoporosis treatment guidelines. Chinese J Osteoporos Bone Miner Res 4 : 2-18.
Cianferotti L, Brandi ML (2012) Guidance for the diagnosis, prevention and therapy of osteoporosis in Italy. Clin Cases Miner Bone Metab 9: 170-8.
Committee of Japanese Guidelines for the Prevention and Treatment of Osteoporosis (2012) The Japanese guidelines for the prevention and treatment of osteoporosis (2011 edition). Life Science Publishing, Tokyo. [ Japanese].
Compston J (2009) Guidelines for prevention and treatment of glucocorticoid-induced osteoporosis. Bone 45: S128-S9.
Czerwiński E, Kanis JA, Osieleniec J et al. (2011) Evaluation of FRAX to characterize fracture risk in Poland. Osteoporos Int 22 : 2507-2512
Czerwinski E, Kanis JA, Trybulec B, Johansson H, Borowy P Osieleniec J (2009) The incidence and risk of hip fracture in Poland. Osteoporos Int 20; 1363-1368
Dawson-Hughes B, Tosteson AN, Melton LJ, III et al. (2008) Implications of absolute fracture risk assessment for osteoporosis practice guidelines in the USA. Osteoporos Int. 19: 449-458.
Dimic A, Sonja SJovan N et al. (2011) Potential role of FRAX analysis in postmenopausal women with osteopenia. Cent Eur J Med 6: 185-189
Douglas F, Petrie KJ, Cundy T, Horne A, Gamble G, Grey A (2012) Differing perceptions of intervention thresholds for fracture risk: a survey of patients and doctors. Osteoporos Int 23: 2135-40.
Edwards FD, Grover ML, Cook CB, Chang Y-HH (2014) Use of FRAX as a determinant for risk-based osteoporosis screening may decrease unnecessary testing while improving the odds of identifying treatment candidates. Womens Health Issues 24: 629-34.
El-Hajj Fuleihan G (2012) 4th Annual meeting of the Lebanese Society of Osteoporosis and Metabolic Bone Disorders, December 2012
El-Hajj Fuleihan G, Chakhtoura, M, Baddoura R (2013) Executive Summary-FRAX—Lebanese FRAX-based guidelines 2013.
Elvey MH, Pugh H, Schaller G, Dhotar G, Patel B, Oddy MJ (2014) Failure in the application of fragility fracture prevention guidelines. Ann Roy Coll f Surg Engl 96: 381-5.
Gadam RK, Schlauch K, Izuora KE (2013) FRAX prediction without BMD for assessment of osteoporosis fracture risk. Endocrine Practice 19: 780-4
Gobierno Federal (2013) Diagnostico y tratamiento de osteoporosis en mujeres postmenopauicas. Guideline IMSS-673-13. Secretary of Health. Accessed 17 October 2015. www.cenetec.salud.gob.mx/interior/gpc.html.
González-Macías J, Del Pino-Montes J, Olmos JM, Nogués X; en nombre de la Comisión de Redacción de las Guías de Osteoporosis de la SEIOMM (2015) Clinical practice guidelines for postmenopausal, glucocorticoid-induced and male osteoporosis. Spanish Society for Research on Bone and Mineral Metabolism (3rd updated version 2014). Rev Clin Esp 215: 515-526
Greenspan SL, Bilezikian JP, Watts NB, et al. (2013) A clinician performance initiative to improve quality of care for patients with osteoporosis. Jo Women’s Health 22: 853-61.
Halldorsson BV, Bjornsson AH, Gudmundsson HT, Birgisson EO, Ludviksson BR, Gudbjornsson B (2015) A clinical decision support system for the diagnosis, fracture risks and treatment of osteoporosis. Comput Math Methods Med 189769. doi: 10.1155/2015/189769
Hosoi T (2012) Clinical application of FRAX in Japan. Clin Calcium 2012; 22: 857-63.
Hosoi T (2015) 2015 Guidelines for Prevention and Treatment of Osteoporosis. Diagnostic criteria of primary osteoporosis and the criteria for pharmacological treatment. Clin Calcium 25: 1279-83.
Hungarian Society for Osteoporosis and Osteoarthrology (HSOO) (2006) National Guidelines. Calcium Bone 8: 116-155
Hwang J-S, Chan D-C, Chen J-F, et al. (2014) Clinical practice guidelines for the prevention and treatment of osteoporosis in Taiwan: summary. J Bone Miner Metab 32: 10-6.
Ip TP, Cheung SK, Cheung TC et al. (2013) OSHK Guideline for clinical management of postmenopausal osteoporosis in Hong Kong. Hong Kong Med J. 19 Suppl 2:1-40. http://www.hkmj.org/supplements/article_pdfs/hkm1304sp2p6.pdf Accessed 24 October 2015
Juozaitytė E, Aleknavičius E, Jančiauskienė R et al. (2014) Guidelines for diagnostics and treatment of aromatase inhibitor-induced bone loss in women with breast cancer: a consensus of Lithuanian medical oncologists, radiation oncologists, endocrinologists, and family medicine physicians. Medicina Kaunas 50: 197-203.
Kanis JA, Burlet N, Cooper C et al. on behalf of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) (2008e) European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 19: 399-428.
Kanis JA, Johansson H, Oden A, McCloskey EV (2009) Bazedoxifene reduces vertebral and clinical fractures in postmenopausal women at high risk assessed with FRAX (R). Bone 44: 1049-54.
Kanis JA, McCloskey EV, Johansson H, Strom O, Borgstrom F, Oden A (2009) How to decide who to treat. Best Practice & Research in Clinical Rheumatology 23: 711-26.
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 (2012e) A systematic review of hip fracture incidence and probability of fracture worldwide. Osteoporos Int 23: 2239-2256.
Khan SN, Craig L, Wild R (2013) Osteoporosis: therapeutic guidelines. Guidelines for practice management of osteoporosis. Clin Obstet Gynecol 56: 694-702.
Kraenzlin ME (2013) Swiss guidance for the diagnosis and management of osteoporosis. Rev Medicale Suisse 9: 1274-8.
Lakatos P, Balogh A, Czerwinski E, et al. (2011) New considerations on the management of osteoporosis in Central and Eastern Europe (CEE): summary of the “3rd Summit on Osteoporosis-CEE”, November 2009, Budapest, Hungary. Arch Osteoporos 6: 1-12.
Lakatos P, Takács I, Szekeres L, et al. (2010) Reumatológiai és Fizioterápiás Szakmai Kollégium: A korral járó és a kortikoszteroidok indukálta osteoporosis diagnosztikus és terápiás protokollja—2011. Háziorvosi Útmutató Klinikai Irányelvek Kézikönyve, Medition Kiadó, Budapest, 3: 215-224 [Hungarian].
Leslie WD, Schousboe JT (2011) A review of osteoporosis diagnosis and treatment options in new and recently updated guidelines on case finding around the world. Curr Osteoporos Rep 9:129–140
Lewiecki EM, Watts NB (2009) New guidelines for the prevention and treatment of osteoporosis. Southern Med J 102: 175-9.
Lin X, Xiong D, Peng Y-Q et al. (2015) Epidemiology and management of osteoporosis in the People’s Republic of China: current perspectives. Clin Interv Aging 10: 1017–1033.
Lippuner K (2012b) Osteoporosis—whom to treat? The importance of FRAX® in Switzerland. Ther Umsch 69:207–213
Lippuner K, Johansson H, Kanis JA, Rizzoli R (2010) FRAX® assessment of osteoporotic fracture probability in Switzerland. Osteoporos Int 21: 381-390
Mendoza N, Sánchez-Borrego R, Villero J et al. (2013) Up-date of the consensus statement of the Spanish Menopause Society on postmenopausal osteoporosis. Maturitas 76: 99-107.
Muncie HL Jr (2014) Guidelines for osteoporosis care for fragility fractures. J Am Geriatr Soc 62: 997-8.
Naranjo A, Ojeda-Bruno S, Francisco-Hernandez F, Erausquin C, Rua-Figueroa I, Rodriguez-Lozano C (2011) Application of guidelines for secondary prevention of fracture and the FRAX index in patients with fragility fracture. Medicina Clinica 136: 290-2.
New Zealand Guidelines Group (NZGG) (2003) Prevention of hip fracture amongst people aged 65 years and over. New Zealand Guidelines Group (NZGG), Wellington,NZ. http://www.moh.govt.nz/NoteBook/nbbooks.nsf/0/9A1DDBCD2ABB9D31CC256DCE006F7073/$file/Hip_Fracture_Prevention_Fulltext.pdf Accessed 14 November 2015
Orimo H (2011) [Bone and calcium update; diagnosis and therapy of metabolic bone disease update. Guideline for prevention and treatment of osteoporosis update]. Clin Calcium 21: 123-43
*Ortega MM, Cárdenas VMM, Alanis AV et al. (2016) Guia de practica clinica sobre el diagnostico y tratamiento de la osteoporosis en la mujer postmenopausica Mexicana. Asociacion Mexicana del Metabolismo y Mineral (AMMOM) https://www.ammom.mx
Orthopedic Society of Chinese Medical Association (2008) Guidelines for osteoporosis fracture management, Chinese Medical Association. Chin J Orthop 28: 875-878
Overman RA, Toliver JC, Yeh J-Y, Gourlay ML, Deal CL (2013) Proportion of US older adults meeting Inclusion criteria for 2010 ACR recommendations on glucocorticoid-induced osteoporosis. Arthritis Rheum 65: S41.
Pavon JM, Sanders LL, Sloane R, Colón-Emeric C (2014) Sensitivity of osteoporosis screening guidelines for eventual hip fracture in older male veterans. Bonekey Rep 7: 530.
Rizzoli R, Adachi JD, Cooper C, et al. (2012) Management of glucocorticoid-Induced osteoporosis. Calcif Tiss Int 91: 225-43.
Royal Australian College o0f General Practitioners (2010) Clinical guideline for the prevention and treatment of osteoporosis in postmenopausal women and older men The Royal Australian College of General Practitioners, 1 Palmerston Crescent, South Melbourne, Vic 3205 Australia ACN 000 223 807, ABN 34 000 223 807, February 2010
Sanfelix-Genoves J, Catala-Lopez F, Sanfelix-Gimeno G, Hurtado I, Baixauli C, Peiro S (2014) Variability in the recommendations for the clinical management of osteoporosis. Medicina Clinica 142: 15-22.
Schweizerische Vereinigung gegen die Osteoporose Switzerland SVGO (2015) Osteoporosis guidelines 2012 http://www.svgo.ch/content/documents/2015/SVGO%20Empfehlungen%202015.pdf Accessed 2 December 2015
Shah TT, Stone M, Kynaston H (2013) Assessing the applicability of the WHO FRAX osteoporotic fracture risk scoring system and national osteoporosis group guidance (NOGG) in patients with prostate cancer on androgen deprivation therapy (ADT). Bju Int 111: 44.
Siris ES, Adler R, Bilezikian J et al. (2014) The clinical diagnosis of osteoporosis: a position statement from the National Bone Health Alliance Working Group. Osteoporos Int 25: 1439-43
Società Italiana dell’Osteoporosi, del Metabolismo Minerale e delle Malattie dello Scheletro (2013) [Guidelines for the diagnosis, prevention and treatment of osteoporosis. Italian Osteoporosis, Mineral Metabolism, and Skeletal Diseases Society]. Minerva Endocrinol 38(1 Suppl 1):1-30. Italian.
Torre I, Perez C, Estopinan L, et al. (2013) Utility of the treatment thresholds in FRAX proposed by the NOF and the NOGG in patients with breast cancer in adjuvant treatment with aromatase inhibitors. Ann Rheum Dis 72: 295.
Triantafyllopoulos IK, Lambropoulou-Adamidou K, Nacopoulos CC et al. (2014) European Menopause and Andropause Society. EMAS position statement: The management of postmenopausal women with vertebral osteoporotic fracture. Maturitas 78: 131-7.
Tsang SWY, Kung AWC, Kanis JA, Johansson H, Oden A (2009) Ten-year fracture probability in Hong Kong Southern Chinese according to age and BMD femoral neck T-scores. Osteoporos Int 20:1939–1945
Tuzun S, Eskiyurt N, Akarirmak U, et al. (2012) The impact of a FRAX-based intervention threshold in Turkey: the FRAX-TURK study. Arch Osteoporos 7: 229-35.
Vondracek SF, Linnebur SA (2009) Diagnosis and management of osteoporosis in the older senior. Clin Interv Aging 4 121–136
Warriner AH, Outman RG, Saag KG et al. (2009) The management of osteoporosis among home health and long term care patients with a prior fracture. South Med J 102: 397–404
Watts NB (2011) Fracture Risk Assessment Tool (FRAX®): applications in clinical practice. J Womens Health 20: 525-31.
World Health Organization (2015) WHO World Report on Ageing and Health (draft Sept 2015). http://who.int/ageing/ageing-global-strategy-draft1-en.pdf Accessed 21 February 2016
*Published after the cut-off date. Recommends an intervention threshold of 20 and 3 % probability of major and hip fracture, respectively.
- Age-dependent threshold
Intervention or assessment threshold of fracture probability that varies with age
- Assessment threshold
The fracture probability at which further assessment id recommended (usually BMD)
- Fixed threshold
Intervention or assessment threshold of fracture probability that is fixed over all ages
- Fracture threshold
The average probability of fracture for a specific age
- Hybrid threshold
Intervention or assessment threshold of fracture probability that partly varies with age and is partly fixed
- Intervention threshold
For this report, the fracture probability at which treatment is recommended
- Major osteoporotic fracture
Fracture of hip, spine (clinical), distal forearm or humerus.
- NOGG strategy
The strategy that describes intervention or assessment threshold of fracture probability that varies with age
In this report, BMD defined: a T-score of between −1 and −2.5
In this report, BMD defined: a T-score of <−2.5
About this article
Cite this article
Kanis, J.A., Harvey, N.C., Cooper, C. et al. A systematic review of intervention thresholds based on FRAX. Arch Osteoporos 11, 25 (2016). https://doi.org/10.1007/s11657-016-0278-z
- Assessment guidelines
- Intervention threshold