Prof. Eugene McCloskey's presentation from Osteoporosis 2016: Fracture Risk assessment tools. Find out more at: https://nos.org.uk/conference

1. Fracture risk assessment tools
The First (but not the last) Antony
Johansen Remedial Lecture
Eugene McCloskey
Professor of Adult Bone Diseases
University of Sheffield
Recipient of the First (but not the last!) Antony
Johansen/Donald Trump Joint Remedial Statistics
Prize

2. The aims in managing osteoporosis
• TO REDUCE THE INCIDENCE OF FRACTURES
• To identify patients at increased risk of fracture
• To be able to assess that risk accurately
• To give advice to aid understanding of the disease, the aims
of therapy and the choice of therapy
• Treatment
• Lifestyle advice
• Therapeutic agents

3. What is the intended use of fracture risk tools?
 Osteoporosis is a common disease
 It should largely be managed in primary care.
 Experts in osteoporosis are used to integrating information
derived from multiple risk factors, but
 most primary care physicians in many countries have little expert
knowledge.
 It is this constituency for which fracture risk tools are primarily
designed
 To increase awareness and knowledge of osteoporosis and to
initiate appropriate treatment in patients at highest risk of
fracture.

4. Risk factors for hip fracture in men and
women
0.0
1.0
2.0
3.0
RR
Without BMD With BMD
Prior
fracture
FH
(hip)
Smoking
current
Alcohol
 3u
Steroids
ever
RA
Kanis JA on behalf of WHO Working Group, Technical Report 2008 (www.shef.ac.uk/FRAX)

5. FRAX Version 3.11
www.shef.ac.uk/FRAX

6. Fracture risk assessment models
QFracture FRAX
Externally validated Yes (UK only) Yes
Calibrated No Yes
Applicability UK 57 countries
Falls input Yes No
BMD input No Yes
Prior fracture input Yes Yes
Family history input Yes Yes
Output Incidence Probability
Treatment response
assessed
No Yes
Thresholds/guidance No Yes

7. NICE SCG Fracture Risk Assessment
• Consider assessment of fracture risk in in all women aged
65 years and over and all men aged 75 years and over .
• Consider fracture risk in women <65 years and men <75
years if they have any of the following risk factors:
• Do not routinely assess fracture risk in people <50 years
unless major risk factors (e.g. GC use, untreated
premature menopause, previous fragility fracture).
• previous fragility fracture
• current or frequent use of oral
glucocorticoids
• history of falls
• family history of hip fracture
• causes of secondary osteoporosis
• low BMI (<18.5 kg/m2)
• smoking >10 cigarettes per day
• alcohol intake > recommend units
Osteoporosis: fragility fracture risk: NICE guideline August 2012

8. • Use either FRAX (without a BMD value) or QFracture to
calculate 10-year predicted absolute fracture risk when
assessing risk of fracture.
• Do not routinely measure BMD to assess fracture risk
without prior assessment using FRAX (without a BMD
value) or QFracture.
Further NICE Recommendations
Osteoporosis: fragility fracture risk: NICE guideline August 2012

9. Risk factors in QFracture-2012/16
• Age
• Sex
• Ethnicity
• Body mass index
• Smoking status
• Alcohol use
• Use of corticosteroids
• Parental history of hip
fracture/osteoporosis
• Prior osteoporotic fracture (wrist,
spine, hip, or shoulder)
• Rheumatoid arthritis or SLE
• History of falls
• Dementia/Nursing or care home
residence
• Type 1 or Type 2 diabetes
• Cancer
• Asthma or COPD
• Cardiovascular disease
• Chronic liver disease
• Chronic kidney disease
• Parkinson's disease
• Gastrointestinal malabsorption
• Epilepsy or use of anticonvulsants
• Use of antidepressants
• Endocrine problems (thyrotoxicosis,
hyperparathyroidism, Cushing’s)
http://qfracture.org; Hippisley-Cox & Copeland, BMJ 2012;344:e3427

10. • Use either FRAX (without a BMD value) or QFracture to
calculate 10-year predicted absolute fracture risk when
assessing risk of fracture in people of between 40 and 84
years.
• Do not routinely measure BMD to assess fracture risk
without prior assessment using FRAX (without a BMD
value) or QFracture.
NICE Recommendations
Osteoporosis: fragility fracture risk: NICE guideline August 2012

11. Absolute risk values are not the same
0
5
10
15
20
25
30
35
40
40 50 60 70 80 90
Qfracture-2012 (Major) Qfracture-2012 (Hip)
FRAX (Major) FRAX (Hip)
Woman with prior fracture, BMI 24, no other CRFs

12. Impact of prior fracture in FRAX and QFracture
Female, no additional risk factors, BMI 25 kg/m2

13. • Following risk assessment with FRAX (without a BMD
value) or QFracture, consider measuring BMD with DXA
in people whose fracture risk is in the region of an
intervention threshold for a proposed treatment, and
recalculate absolute risk using FRAX with the BMD value
• It is out of the scope of this guideline to recommend
intervention thresholds.
o Healthcare professionals should follow local protocols or other
national guidelines for advice on intervention thresholds.
NICE Recommendations
BMD and Intervention Thresholds
Osteoporosis: fragility fracture risk: NICE guideline August 2012

14. Guidance is essential!

15. Case Finding Strategies
CRFs
BMD
T-score
< -2.5
Treat
RCP 1999
CRFs
FRAX
High
Treat
Intermediate Low
BMD
FRAX
High Low
Treat
National Osteoporosis Guideline Group 2008
Compston et al, Maturitas (2009); 62(2):105-8; www.shef.ac.uk/NOGG

16. www.shef.ac.uk/NOGG
0
10
20
30
40
50
40 45 50 55 60 65 70 75 80 85 90
0
10
20
30
40
50
40 45 50 55 60 65 70 75 80 85 90
10 year fracture probability (%)
Age (years)
Consider treatment
No treatment
Consider treatment
No treatment
Age (years)
10 year probability of major osteoporotic fracture (%)
Compston et al, Maturitas (2009); 62(2):105-8; www.shef.ac.uk/NOGG

17. 0
5
10
15
20
25
30
35
40
45
40 45 50 55 60 65 70 75 80 85 90
Age (years)
10-year probability of major osteoporotic fracture (%)
Treat
Measure BMD
Lifestyle advice
and reassure
Updated NOGG Assessment Thresholds
Coming in early 2017…….

18. Letter of invitation
Agree to
take part
CONTROL SCREENING
Intermediate/
High
DXA
Low RiskHigh Risk Unknown
Baseline
Information
Randomisation
Low Risk
• Women aged 70-85 years, not on
anti-osteoporotic medication
identified from GP lists
• 7 geographical regions of the UK
• Randomly allocated to control
(usual management) or
intervention (screening).
• In those subjects deemed at high
risk of hip fracture, family doctor
advised to intervene.
• Follow-up for 5 years.
• Osteoporotic fracture as primary
endpoint; hip fracture and
mortality as secondary
endpoints.
Including FRAX questionnaire
FRAX
FRAX

19. Hip fracture outcome
HR 0.72 (0.59, 0.89) P=0.002
Number needed to screen to prevent one hip fracture = 111

20. Hip fracture reduction by baseline hip fracture
probability
Interaction p=0.021

21. Stepwise
implementation
Objective 1: Improve outcomes and
improve efficiency of care after hip
fractures – by following the 6
“Blue Book” standards
Hip
fracture
patients
Objective 2: Respond to the first
fracture, prevent the second –
through Fracture Liaison
Services in acute and primary
care
Non-hip fragility
fracture patients
Objective 3: Early intervention to
restore independence – through
falls care pathway linking acute
and urgent care services to
secondary falls prevention
Individuals at high risk
of 1st fragility fracture
or other injurious falls
Objective 4: Prevent frailty, preserve
bone health, reduce accidents –
through preserving physical
activity, healthy lifestyles and
reducing environmental hazards
Older people
DoH Falls and Fractures Commissioning
Tool Kit

22. Summary
• NICE has endorsed the use of FRAX or QFracture in the
assessment of fracture risk.
• Clinical utility requires assessment thresholds, integration of
BMD, intervention thresholds and demonstration of
reversibility of risk.
• The SCOOP study demonstrates that a screening program
based on FRAX significantly reduces hip fractures.