Use Of FRAX Research Articles

DXA-Based Measurements in Diabetes: Can They Predict Fracture Risk?

In the absence of a fragility fracture, osteoporosis is usually diagnosed from bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA). Osteoporosis is an increasingly prevalent disease, as is diabetes [in particular type 2 diabetes (T2D)], in part due to aging populations worldwide. It has been suggested that an increased risk of fracture may be another complication ensuing from longstanding diabetes. The purpose of this review is to concentrate on skeletal parameters and techniques readily available from DXA scanning, and their utility in routine clinical practice for predicting fracture risk. In addition to BMD, other applications and measures from DXA include trabecular bone score (TBS), skeletal geometry and DXA-based finite-element analysis, vertebral fracture assessment, and body composition. In type 1 diabetes (T1D), BMD and FRAXR (when secondary osteoporosis is included without BMD) only partially account for the excess risk of fracture in T1D. Consistent data exist to show that BMD and FRAXR can be used to stratify fracture risk in T2D, but do not account for the increased risk of fracture. However, several adjustments to the FRAX score can be made as proxies for T2D to inform the use of FRAX by primary care practitioners. Examples include using the rheumatoid arthritis input (as a proxy for T2D), lumbar spine TBS (to adjust FRAX probability) or an altered hip T-score (lowered by 0.5 units). These adjustments can improve fracture risk prediction in T2D and help to avoid systematically underestimating the risk of osteoporosis-related fractures in those with diabetes.

PROGNOSTIC VALUE OF X-RAY DENSITOMETRY IN OSTEOPOROSIS

Introduction of X-ray densitometry had revolutionized the diagnostics of osteoporosis. Majority of scientists believed that it was a diagnostic instrument close to almost ideal one capable evaluation of both: bone mineral density and likelihood of future fractures. Experiences accumulated during the previous years have slightly shaken this belief. It is more frequently heard that DEXA is not an ideal diagnostic instrument, but no better instrument has been created yet, which is also proved by our 12 years of experience. Materials and Methods. X-ray densitometry research evaluated 5200 patients aged 40-70. 4100 women and 1100 men. Medical History of 825 patients showed that they had bone fractures, 136 out of them were high energy ( pressure), the rest of them low trauma or no-trauma fractures. BMD index was low in 2736 patients (T score> -2.5). 48 patients had fractures in earlier lives registered in their medical records. Results. Low BMD index was identified in 2736 patients with osteoporosis only during the DXA lateral scans. It is arguable thatx-ray densitometry and BMD evaluation is the only criteria for the standards of diagnostics and the predictor of progressive bone loss and fractures. Discussion. While analyzing the results, diagnostic problems emerged at diagnostic process were taken into account, namely spine deformation, osteoporosis, osteochondrosis that camouflage real mineral density of the bones. At the same time, each patients with existing fractures in their record filled in special questionnaires describing clinical symptoms of the disease and risk-factors influencing the likelihood of the disease. Results of the work were processed through the analysis of variance (Fisher). Reliable correlation was not identified between DXA results and fracture risk index. This last one encourages routine use of FRAX in diagnostics of osteoporosis and prognosis of fractures before morphological evaluation of bones will be readily available to use as an additional diagnostic tool.

A systematic review of intervention thresholds based on FRAX : A report prepared for the National Osteoporosis Guideline Group and the International Osteoporosis Foundation.

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 (≥70years) 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.

FRAX updates 2016.

In the 8 years since the launch of the FRAX tool, it has continued to grow with the addition of new country or territory models. Although the core of the fracture risk algorithm remains unchanged, there is growing evidence of possible additional independent clinical variables that might modulate the interpretation of the FRAX outputs. There is also an expanding number of international guidelines that incorporate FRAX assessments, leading to discussions on the use of FRAX in treated patients and the determination of intervention thresholds. This review encompasses recent information on the use of FRAX in immigrant populations and the potential influence of skeletal and extraskeletal risk factors on FRAX estimations. For example, trabecular bone score and falls risk appear to be promising additional factors in individual risk assessment. FRAX appears to remain accurate in those on osteoporosis treatments, but FRAX is not a suitable tool for use in treat-to-target strategies. The assessment of fracture risk in immigrants is probably more accurate with the use of the FRAX tool for the country of origin, if available. The impact of additional risk variables will need evaluation of the impact of these on recharacterizing patients by moving them across intervention thresholds.

SIGN Guidelines for Scotland: BMD Versus FRAX Versus QFracture.

Scottish Intercollegiate Guidelines Network (SIGN) recently issued guidance on the management of osteoporosis and the prevention of fragility fractures. The aim of this paper was to critically review the guidance. The SIGN guidance utilises risk factors for fracture as an initial step for assessment, but recommends treatment only in individuals with a T-score of -2.5. There are many problems with the sole use of BMD as the sole gateway to treatment. Moreover, the assessment tools to determine risk (FRAX or QFracture) are not designed to detect osteoporosis but rather fracture risk. Whereas SIGN assumes that FRAX overestimates fracture probability, there are compelling reasons to believe that the disparity is related to the inadequate calibration of QFracture. The disparities make the use of a single threshold for BMD testing problematic. The SIGN guidance for men at high risk of fracture provides a set of confused and inconsistent recommendations that are in direct conflict with regulatory authorizations and is likely to increase further the large treatment gap in men. For women, the number of women eligible for treatment (i.e. with osteoporosis) is 81,700 with the use of FRAX but only 12,300 with QFracture representing 8.2 and 1.2% of the total population at risk, respectively. We conclude that serious problems with the SIGN guidance preclude its implementation.

Prediction of fracture risk in patients with osteoporosis: a brief review.

Osteoporosis, a well-defined and growing public health problem, is a disease characterized by increased bone turnover and decreased bone mass with associated skeletal fragility, resulting in an increased risk of fracture. It is often unrecognized until the late stages when fragility fractures have occurred. In adults, early recognition of the disease prior to the occurrence of fractures followed by timely and efficient initiation of appropriate treatment can reduce fracture risk. In this article, we review clinical modalities available to effectively predict fracture risk in patients with osteoporosis. Bone mineral density and presence of clinical risk factors may be combined to provide a more comprehensive osteoporotic fracture risk assessment. Use of FRAX may serve as a general guideline for clinical management and deciding a threshold for cost-effective pharmacological intervention. Elevated bone turnover markers are predictive of high fracture risk and can provide additional clinical information as well.

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.

FRAX(©) evaluates 10-year fracture probabilities and can be calculated with and without bone mineral density (BMD). Low socioeconomic status (SES) may affect BMD, and is associated with increased fracture risk. Clinical risk factors differ by SES; however, it is unknown whether aninteraction exists between SES and FRAX determined with and without the BMD. From the Geelong Osteoporosis Study, we drew 819 females aged ≥50 years. Clinical data were collected during 1993-1997. SES was determined by cross-referencing residential addresses with Australian Bureau of Statistics census data and categorized in quintiles. BMD was measured by dual energy X-ray absorptiometry at the same time as other clinical data were collected. Ten-year fracture probabilities were calculated using FRAX (Australia). Using multivariable regression analyses, we examined whether interactions existed between SES and 10-year probability for hip and any major osteoporotic fracture (MOF) defined by use of FRAX with and without BMD. We observed a trend for a SES * FRAX(no-BMD) interaction term for 10-year hip fracture probability (p = 0.09); however, not for MOF (p = 0.42). In women without prior fracture (n = 518), we observed a significant SES * FRAX(no-BMD) interaction term for hip fracture (p = 0.03) and MOF (p = 0.04). SES does not appear to have an interaction with 10-year fracture probabilities determined by FRAX with and without BMD in women with previous fracture; however, it does appear to exist for those without previous fracture.

The Fracture Risk Assessment Tool (FRAX score) in subclinical hyperthyroidism.

The Fracture Risk Assessment Tool (FRAX score) is the 10-year estimated risk calculation tool for bone fracture that includes clinical data and hip bone mineral density measured by dual-energy x-ray absorptiometry (DXA). The aim of this cross-sectional study was to elucidate the ability of the FRAX score in discriminating between bone fracture positive and negative pre- and postmenopausal women with subclinical hyperthyroidism. The bone mineral density (by DXA), thyroid stimulating hormone (TSH) level, free thyroxine (fT4) level, thyroid peroxidase antibodies (TPOAb) titre, osteocalcin and beta-cross-laps were measured in 27 pre- and postmenopausal women with newly discovered subclinical hyperthyroidism [age 58.85 +/- 7.83 years, body mass index (BMI) 27.89 +/- 3.46 kg/m2, menopause onset in 46.88 +/- 10.21 years] and 51 matched euthyroid controls (age 59.69 +/- 5.72 years, BMI 27.68 +/- 4.66 kg/m2, menopause onset in 48.53 +/- 4.58 years). The etiology of subclinical hyperthyroisims was autoimmune thyroid disease or toxic goiter. FRAX score calculation was performed in both groups. In the group with subclinical hyperthyroidism the main FRAX score was significantly higher than in the controls (6.50 +/- 1.58 vs. 4.35 +/- 1.56 respectively; p = 0.015). The FRAX score for hip was also higher in the evaluated group than in the controls (1.33 +/- 3.92 vs. 0.50 +/- 0.46 respectively; p = 0.022). There was no correlations between low TSH and fracture risk (P > 0.05). The ability of the FRAX score in discriminating between bone fracture positive and negative pre- and postmenopausal female subjects (p < 0.001) is presented by the area under the curve (AUC) plotted via ROC analysis. The determined FRAX score cut-off value by this analysis was 6%, with estimated sensitivity and specificity of 95% and 75.9%, respectively. Pre- and postmenopausal women with subclinical hyperthyroidism have higher FRAX scores and thus greater risk for low-trauma hip fracture than euthyroid premenopausal women. Our results point to the use of FRAX calculator in monitoring pre- and postmenopausal women with subclinical hyperthyroidism to detect subjects with high fracture risk in order to prevent further fractures.

FRAX® thresholds to identify people with high or low risk of osteoporotic fracture in Spanish female population

Background and objectiveTo detect FRAX® threshold levels that identify groups of the population that are at high/low risk of osteoporotic fracture in the Spanish female population using a cost-effective assessment. Patients and methodsThis is a cohort study. Eight hundred and sixteen women 40–90 years old selected from the FRIDEX cohort with densitometry and risk factors for fracture at baseline who received no treatment for osteoporosis during the 10 year follow-up period and were stratified into 3 groups/levels of fracture risk (low <10%, 10–20% intermediate and high >20%) according to the real fracture incidence. ResultsThe thresholds of FRAX® baseline for major osteoporotic fracture were: low risk <5; intermediate ≥5 to <7.5 and high ≥7.5. The incidence of fracture with these values was: low risk (3.6%; 95% CI 2.2–5.9), intermediate risk (13.7%; 95% CI 7.1–24.2) and high risk (21.4%; 95% CI 12.9–33.2). The most cost-effective option was to refer to dual energy X-ray absorptiometry (DXA-scan) for FRAX®≥5 (Intermediate and high risk) to reclassify by FRAX® with DXA-scan at high/low risk. These thresholds select 17.5% of women for DXA-scan and 10% for treatment. With these thresholds of FRAX®, compared with the strategy of opportunistic case finding isolated risk factors, would improve the predictive parameters and reduce 82.5% the DXA-scan, 35.4% osteoporosis prescriptions and 28.7% cost to detect the same number of women who suffer fractures. ConclusionsThe use of FRAX® thresholds identified as high/low risk of osteoporotic fracture in this calibration (FRIDEX model) improve predictive parameters in Spanish women and in a more cost-effective than the traditional model based on the T-score≤−2.5 of DXA scan.

Use of FRAX as a Determinant for Risk-Based Osteoporosis Screening May Decrease Unnecessary Testing While Improving the Odds of Identifying Treatment Candidates

PurposeWe have assessed the hypothetical impact of guideline-concordant osteoporosis screening on baseline behaviors utilizing two different guidelines and determined the relative ability of each to identify osteoporosis treatment candidates. MethodsWe conducted secondary analyses from the Fracture Risk Perception Study, which enrolled patients aged 50 to 75 years to complete questionnaires about their bone health. We determined our baseline screening rates and detection of treatment candidates and then assessed the hypothetical impact of adherence to U.S. Preventive Services Task Force (USPSTF) and National Osteoporosis Foundation (NOF) criteria, particularly for women aged 50 to 64. ResultsOf 144 women aged 50 to 64 years screened, 14 (9.7%) were treatment candidates. Screening based on identification of one or more risks (NOF) would lead to testing of 102 of the 144 patients (71%) to identify 12 of 14 treatment candidates (86%). Applying USPSTF criteria (9.3% FRAX threshold) would test 45 of the same 144 women (31%) to identify 11 of 14 treatment candidates (79%). NOF risk-based criteria would result in a moderate absolute screening rate reduction (16%, p = .0011; 95% CI, 7%–25%), but only marginal improvement in identifying treatment candidates (odds ratio, 2.67; 95% CI, 0.57–12.47). Applying the more selective USPSTF criteria greatly reduced unnecessary testing (56% absolute screening rate reduction; p < .0001; 95% CI, 47%–64%) while further improving the odds of identifying treatment candidates (odds ratio, 10.35; 95% CI, 2.72–39.35). ConclusionsWhen contemplating screening younger patients, systematic calculation of FRAX and ordering only when the 9.3% fracture risk threshold is reached may decrease unnecessary screening for many women while still identifying appropriate osteoporosis treatment candidates.

PTH-114 Assessing Osteoporosis In Coeliac Disease: Is The Who Frax Tool A Good Screener?

IntroductionOsteoporosis is a well-recognised complication of intestinal malabsorption related to Coeliac Disease. It is diagnosed by dual energy x-ray absorptiometry (DXA). While referral for DXA scanning in other conditions is...

Umbrales de FRAX® para identificar personas con alto o bajo riesgo de fractura osteoporótica en población femenina española

Background and objectiveTo detect FRAX® threshold levels that identify groups of the population that are at high/low risk of osteoporotic fracture in the Spanish female population using a cost-effective assessment. Patients and methodsThis is a cohort study. Eight hundred and sixteen women 40-90 years old selected from the FRIDEX cohort with densitometry and risk factors for fracture at baseline who received no treatment for osteoporosis during the 10 year follow-up period and were stratified into 3 groups/levels of fracture risk (low<10%, 10-20% intermediate and high>20%) according to the real fracture incidence. ResultsThe thresholds of FRAX® baseline for major osteoporotic fracture were: low risk<5; intermediate≥5 to <7.5 and high≥7.5. The incidence of fracture with these values was: low risk (3.6%; 95% CI 2.2-5.9), intermediate risk (13.7%; 95% CI 7.1-24.2) and high risk (21.4%; 95% CI12.9-33.2). The most cost-effective option was to refer to dual energy X-ray absorptiometry (DXA-scan) for FRAX®≥5 (Intermediate and high risk) to reclassify by FRAX® with DXA-scan at high/low risk. These thresholds select 17.5% of women for DXA-scan and 10% for treatment. With these thresholds of FRAX®, compared with the strategy of opportunistic case finding isolated risk factors, would improve the predictive parameters and reduce 82.5% the DXA-scan, 35.4% osteoporosis prescriptions and 28.7% cost to detect the same number of women who suffer fractures. ConclusionsThe use of FRAX ® thresholds identified as high/low risk of osteoporotic fracture in this calibration (FRIDEX model) improve predictive parameters in Spanish women and in a more cost-effective than the traditional model based on the T-score ≤ -2.5 of DXA scan.

Consensus of Official Position of IOF/ISCD FRAX Initiatives in Asia-Pacific Region

The fracture risk assessment tool (FRAX®) has been developed for the identification of individuals with high risk of fracture in whom treatment to prevent fractures would be appropriate. FRAX models are not yet available for all countries or ethnicities, but surrogate models can be used within regions with similar fracture risk. The International Society for Clinical Densitometry (ISCD) and International Osteoporosis Foundation (IOF) are nonprofit multidisciplinary international professional organizations. Their visions are to advance the awareness, education, prevention, and treatment of osteoporosis. In November 2010, the IOF/ISCD FRAX initiative was held in Bucharest, bringing together international experts to review and create evidence-based official positions guiding clinicians for the practical use of FRAX. A consensus meeting of the Asia-Pacific (AP) Panel of the ISCD recently reviewed the most current Official Positions of the Joint Official Positions of ISCD and IOF on FRAX in view of the different population characteristics and health standards in the AP regions. The reviewed position statements included not only the key spectrum of positions but also unique concerns in AP regions.

AB0621 Fraxture – does frax reflect the risk of fracture in real practice?

BackgroundThe Fracture Risk Assessment Tool (FRAX) has been developed as an algorithm to evaluate the 10-year risk of hip and major osteoporotic fractures, based on clinical risk factors, with or...

THU0404 A Comparative Study of FRAX Vs DEXA in Predicting Osteoporotic Fracture Risk

BackgroundOsteoporosis is a disease characterised by low bone mass and structural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. Case finding strategies form...

Congress Report: 5th Central and Eastern Europe (CEE) Summit on Osteoporosis in Bratislava, 2–3 December 2011

Major aims of the 5th Central and Eastern Europe (CEE) Summit on Osteoporosis held in Bratislava, Slovakia, on 2 and 3 December 2011, were to provide participants with state-of-the-art knowledge in the fields of osteoporosis research, diagnosis, and therapy and to evaluate, compare, and discuss the very heterogeneous health care situations and related challenges in the different countries in CEE and elsewhere. The summit was attended by 70 delegates from 15 countries. State-of-the-art lectures given by international authorities on osteoporosis covered a broad spectrum of topics ranging from osteoporosis in the male population, novel therapies in osteoporosis such as cathepsin K and sclerostin inhibitors, and the implementation and use of FRAX® in CEE, to an update on denosumab for the management of osteoporosis. Workshops organized to enable the exchange of individual experiences addressed the importance and current availability of osteology training for physicians and the impact of patient training programs on therapy compliance. Furthermore, the availability of and need for standardized quality controls and therapy guidelines in different CEE countries were discussed. Finally, based on a questionnaire, a very up-to-date analysis of all participating countries regarding incidences of osteoporosis, commonly used diagnostic and therapeutic measures, the number of specialists and specialized hospitals, and differences in the reimbursement situation in the different countries was generated and presented. On the whole, the very authentic contributions and the synergistic exchange of ideas allowed the identification of both positive developments as well as still existing issues and needs in diagnosis and therapy of osteoporosis.

FRAX and the assessment of the risk of developing a fragility fracture

Osteoporosis is common and the health and financial cost of fragility fractures is considerable. The burden of cardiovascular disease has been reduced dramatically by identifying and targeting those most at risk. A similar approach is potentially possible in the context of fragility fractures. The World Health Organization created and endorsed the use of FRAX, a fracture risk assessment tool, which uses selected risk factors to calculate a quantitative, patient-specific, ten-year risk of sustaining a fragility fracture. Treatment can thus be based on this as well as on measured bone mineral density. It may also be used to determine at-risk individuals, who should undergo bone densitometry. FRAX has been incorporated into the national osteoporosis guidelines of countries in the Americas, Europe, the Far East and Australasia. The United Kingdom National Institute for Health and Clinical Excellence also advocates its use in their guidance on the assessment of the risk of fragility fracture, and it may become an important tool to combat the health challenges posed by fragility fractures.

New actions of rank ligand

increased fracture risk occur early after therapy is initiated, emphasising the importance of primary prevention of fracture in high-risk individuals. Most currently available guidelines for the management of GIO were developed prior to the release of FRAX® and other risk assessment tools and the approval of newer pharmacological interventions for its management. The need for updated guidelines for Europe and other parts of the world was recognised by the International Osteoporosis Foundation (IOF) and the European Calcified Tissue Society (ECTS), which set up a joint Guideline Working Group at the end of 2010. The aim of this group was to provide a framework for the development of guidelines from which countryspecific recommendations could be derived. The framework covers the management of GIO in men and women aged 18 years or over, in whom continuous oral glucocorticoid therapy at any dose is considered for 3 months or longer. All interventions approved for GIO worldwide are included. The guidelines recommend the use of FRAX for risk assessment, with adjustment for the dose of glucocorticoid. Bone protective therapy should be started at the onset of glucocorticoid therapy in individuals at increased risk of fracture, for example postmenopausal women and older men with a previous history of fracture, women and men aged ≥70 years, and postmenopausal women and men aged ≥50 years taking high doses of glucocorticoids. A BMD T-score of ≤−1.5 in postmenopausal women and older men may also be considered as an indication for bone protective therapy. The fracture probability at which pharmacological intervention is advised varies between countries depending on local factors such as reimbursement policies, health economics, willingness to pay and availability of dual-energy X-ray absorptiometry (DXA). This article is part of a Special Issue entitled ECTS 2012. Disclosure of interest: None declared.

FRAX® counseling for bone health behavior change in women 50 years of age and older

To evaluate the use of FRAX® (Fracture risk assessment tool) for changes in bone health risk factors and treatment decision-making. A convenience sample of seventeen women, 50 years and older, English-speaking, generally healthy, with the ability to perform weight-bearing exercise, presenting for a DXA scan in a Midwestern city between August 2009 and November 2009, and not already being treated for osteoporosis or osteopenia. Self-administered diet and exercise questionnaires were completed by participants, followed by individual counseling related to FRAX® absolute risk and NOF guidelines. Questionnaires were repeated at approximately three months later, along with a short survey regarding the information's impact. FRAX® increased a participant's perception of future risk for osteoporosis and desire to change bone health habits. About 50% actually made changes in calcium and vitamin D consumption and weight-bearing exercise. FRAX® could not be applied to those with osteopenia of the spine only; and a variety of bone health risk factors not covered by FRAX® were identified. The FRAX® risk assessment tool can be useful to motivate clients to change bone health behavior. However, it has limitations in its use as a tool for whether or not to prescribe bisphosphonates.

FRAX® with and without Bone Mineral Density

The use of FRAX, particularly in the absence of BMD, has been the subject of some debate and is the focus of this review. The clinical risk factors used in FRAX have high validity as judged from an evidence-based assessment and identify a risk that is responsive to pharmaceutical intervention. Moreover, treatment effects, with the possible exception of alendronate, are not dependent on baseline BMD and strongly suggest that FRAX identifies high-risk patients who respond to pharmaceutical interventions. In addition, the selection of high-risk individuals with FRAX, without knowledge of BMD, preferentially selects for low BMD. The prediction of fractures with the use of clinical risk factors alone in FRAX is comparable to the use of BMD alone to predict fractures and is suitable, therefore, in the many countries where DXA facilities are sparse. In countries where access to BMD is greater, FRAX can be used without BMD in the majority of cases and BMD tests reserved for those close to a probability-based intervention threshold. Whereas the efficacy for agents to reduce fracture risk has not been tested prospectively in randomized controlled trials in patients selected on the basis of FRAX probabilities, there is compelling evidence that FRAX with or without the use of BMD provides a well-validated instrument for targeting patients most likely to benefit from an intervention.