If You Have Osteopenia, How High is Your Fracture Risk? The FRAX Algorithm

Health Professional

For many who take the diligent step of undergoing a bone densitometry scan to learn about the status of their bone health, the test can provide answers - and more questions. For a T-score greater than -2.5, which is considered a diagnosis of osteoporosis, the consensus among most doctors is that treatment is necessary. But for a vast number of women and men diagnosed with osteopenia, or diminished bone mass defined as a T-score of -1 to -2.5, the ideal course of action can be less well defined.

Osteopenia and Fracture Risk

Osteopenia is a serious condition, which if left untreated can result in further bone loss. Of even greater concern is that more than half of fractures occur in individuals with osteopenia rather than full-fledged osteoporosis. Yet prescription osteoporosis medication can be expensive, onerous to take, and have unpleasant or even painful side effects.

The most commonly prescribed drugs, bisphosphonates such as Fosamax, Boniva and Actonel, require remaining upright for at least half an hour after taking the medication, and have been associated with gastrointestinal discomfort such as heartburn or difficulty swallowing.

To Treat Osteopenia, What's the Best Choice?

Many individuals who have osteopenia do not go on to experience further bone loss or a related fracture, even without treatment. If the risk of breaking a bone is considered minute, taking drugs to increase bone mass may be unnecessary; a healthy lifestyle with adequate consumption of calcium and Vitamin D may be sufficient instead. But how do we know if this is indeed the case?

In the past, determining the right treatment plan for those in the gray area - an estimated 30 million individuals are believe to have osteopenia nationwide - depended on a doctor's subjective judgment after weighing the T-score along with other known risk factors for the disease, such as family history, a sedentary routine, smoking, excessive alcohol intake and other medical conditions known to affect bone health. But now physicians have access to a powerful new tool to assist in making the best call for a particular patient.

The FRAX Algorithm and Fracture Risk

FRAX is an algorithm developed by the World Health Organization to determine absolute fracture risk, or the probability that a given person will suffer a hip or other major osteoporosis-related fracture (in the vertebra, hip, forearm or upper arm) during the next 10 years. It incorporates data on thousands of people from around the world to calculate the chance of breaking a bone based on the T-score combined with other known factors that can contribute to osteoporosis. A health professional can then use this tool to make a more informed recommendation than would be possible with just the results of a bone densitometry test, commonly known as a DXA scan.

FRAX is a tool that "allows us to talk to patients about their risk... who needs treatment beyond the universal recommendations of calcium, Vitamin D and exercise," says Dr. Ethel S. Siris, an endocrinologist who serves as a president of the National Osteoporosis Foundation.

The Purpose of FRAX Relative to Osteopenia

Dr. Siris emphasizes that the objective of FRAX is not to increase the total number of patients with osteopenia who receive medication, nor in any case to discontinue treatment when a physician considers a patient at risk. The goal is to better pinpoint the individuals on the cusp who might be most in need of taking further action in regards to their bone health.

The algorithm is a prominent component of the National Osteoporosis Foundation's "2008 Clinician's Guide to Prevention and Treatment of Osteoporosis," which also incorporates data specific to the United States.

The Guide discusses how to prevent osteoporosis and provides doctors the latest information about the diagnosis and treatment of those with osteopenia and osteoporosis. Specifically, the Guide recommends that patients with low bone mass be treated when the 10-year absolute fracture risk is 3 percent or greater for a hip fracture and 20 percent or greater for other major osteoporosis breaks.

Who Should Consider FRAX?

My mother is the perfect example of a person who stands to benefit from FRAX. A DXA scan in 2006 indicated that she suffers from osteopenia, with a T-score in her hip of -1.93. Her doctor discussed prescribing medication, but my mother, herself a physician, declined. However, once her risk factors were inputted into the calculation tool, the results appeared in seconds. According to the algorithm, she has 3.6 percent chance of a hip fracture within the next 10 years and a 41 percent chance of a major osteoporotic fracture overall. These concerning statistics are well above the threshold at which treatment is recommended, and clearly suggest another conversation with her doctor is in order.

The use of FRAX promises to be especially helpful for nonwhite women and for men over 50, since previous calculations had largely been based on Caucasian postmenopausal women, who tend to have the greatest chance of suffering a fracture related to low bone mass. Because other groups have a comparatively lower risk of developing osteoporosis, doctors have sometimes neglected to diagnose and treat the condition among the individuals who do have the condition.

FRAX and Fracture Risk in Men

"It turns out the risk in men is quite substantial," says Dr. Robert Lindsay, Chief of Internal Medicine at the Helen Hayes Hospital in New York and one of the Guide's co-authors. "There are a lot of men out there who are not being diagnosed," sometimes even despite suffering fractures, he adds. Utilizing the FRAX algorithm could help doctors determine which men with low bone mass could stand to benefit the most from treatment.

In the future, it is conceivable that patients undergoing a bone densitometry test would receive a report of their FRAX results at the time of their DXA scans. More immediately, this web-based tool can be used in the doctor's office in conjunction with T-score results to help physicians and patients make individualized treatment decisions together.

A Firsthand Look at FRAX

One can take a firsthand look at FRAX at www.shef.ac.uk/FRAX, but remember the tool is intended to be used by health care professionals with the expertise necessary to answer the questions accurately and recommend appropriate treatment options. Never start or stop medication without consulting with your doctor first. But if your doctor is not yet familiar with this methodology, a discussion about FRAX may be good way to kick-start the conversation about your bone health.