Joint Official Positions of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX®: Executive Summary of the 2010 Position Development Conference on Interpretation and Use of FRAX® in Clinical Practice

doi:10.1016/j.jocd.2011.05.007

Journal of Clinical Densitometry

Volume 14, Issue 3, July 2011, Pages 171-180

https://doi.org/10.1016/j.jocd.2011.05.007 Get rights and content

Abstract

The International Society for Clinical Densitometry (ISCD) and the International Osteoporosis Foundation (IOF) convened the FRAX^® Position Development Conference (PDC) in Bucharest, Romania, on November 14, 2010, following a two-day joint meeting of the ISCD and IOF on the “Interpretation and Use of FRAX^® in Clinical Practice.” These three days of critical discussion and debate, led by a panel of international experts from the ISCD, IOF and dedicated task forces, have clarified a number of important issues pertaining to the interpretation and implementation of FRAX^® in clinical practice. The Official Positions resulting from the PDC are intended to enhance the quality and clinical utility of fracture risk assessment worldwide. Since the field of skeletal assessment is still evolving rapidly, some clinically important issues addressed at the PDCs are not associated with robust medical evidence. Accordingly, some Official Positions are based largely on expert opinion. Despite limitations inherent in such a process, the ISCD and IOF believe it is important to provide clinicians and technologists with the best distillation of current knowledge in the discipline of bone densitometry and provide an important focus for the scientific community to consider. This report describes the methodology and results of the ISCD-IOF PDC dedicated to FRAX^®.

Introduction

The International Society for Clinical Densitometry (ISCD) is an international non-profit professional society linking multiple disciplines with an interest in bone mass measurement and assessment of skeletal integrity. The ISCD's mission is to advance excellence in skeletal health assessment by: promoting education and a broader understanding of the clinical applications of bone mass measurement and other skeletal health assessment technologies; assuring proficiency and quality in the assessment of skeletal health through certification and accreditation; supporting clinical and scientific advances in the diagnosis and treatment of osteoporosis; and promoting appropriate patient access to bone mass measurement and other skeletal health assessment technologies. As skeletal health assessment evolves, differences develop in technologies, acquisition techniques, reference databases, reporting methods, terminology and osteoporotic fracture prediction. These differences may result in adverse effects on patient care and the exchange of scientific information. To address these issues, the ISCD periodically holds Position Development Conferences (PDCs), a process whereby an international panel of experts makes recommendations based on reviews of the scientific literature by ISCD Task Forces. Recommendations that are approved by the ISCD Board of Directors become Official Positions of the ISCD. Official Positions resulting from prior PDCs held biannually from 2001–2007 have previously been reported 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29.

The International Osteoporosis Foundation (IOF) is a non-profit, non-governmental umbrella organization dedicated to the worldwide fight against osteoporosis, the disease known as “the silent epidemic”. The IOF’s members – committees of scientific researchers, patients, medical and research societies and industry representatives from around the world – share a common vision of a world without osteoporotic fractures. The IOF now represents 195 societies in 93 locations.

The ultimate aim of the clinician in the management of osteoporosis should be to reduce the risk of fractures. Treatment decisions should be made through good clinical judgment and improved identification of patients at high risk. FRAX^® (http://www.shef.ac.uk/FRAX) is a simple computer-based tool that integrates clinical information and femoral neck BMD as an option to predict the 10-year probability of major osteoporotic fracture and hip fracture 30, 31. It can be customized for use in both women and men over the age of 40 years and for different countries based upon local epidemiology of fracture and death. Developed at the World Health Organization Collaborating Centre for Metabolic Bone Diseases, University of Sheffield, UK, in collaboration with other scientific societies, the tool assists primary health care providers to better target patients for pharmacological intervention, ultimately improving the allocation of scarce healthcare resources for patients most likely to benefit from treatment.

FRAX is being used by an increasing number of clinicians around the world. However, the widespread application of FRAX in clinical practice has raised numerous questions regarding the information selected for input and the possible underestimation or overestimation of fracture risk in specific instances. In order to assist clinicians in deriving the greatest possible clinical value from using FRAX, the ISCD, in collaboration with the IOF, convened the FRAX PDC in Bucharest, Romania, on November 14, 2010, following a two-day collaborative meeting of the ISCD and IOF - “Interpretation and Use of FRAX in Clinical Practice.” These three days of critical discussion and debate, led by a panel of international experts from the ISCD, IOF and dedicated task forces, clarified a number of important issues pertaining to the interpretation and use of FRAX in clinical practice.

This report describes the methodology and results of the 2010 Bucharest, Romania ISCD-IOF PDC that was dedicated to FRAX.

The ISCD Official Positions resulting from a PDC are established in order to enhance the quality and clinical utility of skeletal assessment worldwide. However because the skeletal assessment field is still evolving rapidly, some clinically important issues addressed at the PDCs are not associated with robust medical evidence. Accordingly, some Official Positions are based largely on expert opinion. Despite limitations inherent in such a process, the ISCD and IOF believe it is appropriate to provide clinicians and technologists with the best distillation of current knowledge in the discipline of bone densitometry and provide an important focus for the scientific community to consider further research to resolve areas of ambiguity and/or ongoing controversy.

The ISCD and IOF wish to acknowledge the extraordinary efforts of the PDC Task Force Chairpersons and members, who represented a distinguished group of international experts. The dedication of these individuals for the past two years is exemplary.

Section snippets

Topic Selection

Topics addressed at the 2010 PDC were selected by the ISCD Board of Directors (BOD), Scientific Advisory Committee (SAC) and the PDC Steering Committee according to criteria used for prior PDCs 1, 2, 14. The topics selected were reviewed by and had the full scientific participation of the executive committee of the IOF. Each topic selected had been judged to be clinically relevant with a perceived need for an Official Position due to lack of overwhelming medical evidence or due to its

Participants

The FRAX Initiative was comprised of the Organizers, Task Force liaisons, the three Task Forces, Moderators and the Expert Panel. Details of the participants can be found in Appendix.

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Positions of The International Society for Clinical Densitometry and Their Etiology: A Scoping Review
2023, Journal of Clinical Densitometry
The International Society for Clinical Densitometry convenes a Position Development Conference (PDC) every 2 to 3 years to make recommendations for guidelines and standards in the field of musculoskeletal measurement and assessment. The recommendations pertain to clinically relevant issues regarding the acquisition, quality control, interpretation, and reporting of measures of various aspects of musculoskeletal health. These PDCs have been meeting since 2002 and have generated 214 Adult, 26 FRAX, 41 pediatric, and 9 general nomenclature consideration positions, for a total of 290 positions. All positions are justified by detailed documents that present the background and rationale for each position. However, the linkage to these publications is not maintained by the ISCD or any other publication such that physicians cannot easily understand the etiology of the positions. Further, the wording of many positions has changed over the years after being reviewed by subsequent PDCs. This scoping review captures the references, changes, and timeline associated with each position through the 2019 PDC. It is meant to serve as a guide to clinicians and researchers for intelligent use and application of the positions.
Clinical practice guidelines for the prevention and treatment of osteoporosis in Taiwan: 2022 update
2023, Journal of the Formosan Medical Association
Osteoporosis greatly increases the risk of fractures. Osteoporotic fractures negatively impact quality of life, increase the burden of care, and increase mortality. Taiwan is an area with a high prevalence of osteoporosis. This updated summary of guidelines has been developed by experts of the Taiwan Osteoporosis Association with the intention of reducing the risks of osteoporotic fractures and improving the quality of care for patients with osteoporosis. The updated guidelines compile the latest evidence to provide clinicians and other healthcare professionals with practical recommendations for the prevention, diagnosis, and management of osteoporosis under clinical settings in Taiwan.
Circulating serum microRNAs including senescent miR-31-5p are associated with incident fragility fractures in older postmenopausal women with type 2 diabetes mellitus
2022, Bone
Fragility fractures are an important hallmark of aging and an increasingly recognized complication of Type 2 diabetes (T2D). T2D individuals have been found to exhibit an increased fracture risk despite elevated bone mineral density (BMD) by dual x-ray absorptiometry (DXA). However, BMD and FRAX-scores tend to underestimate fracture risk in T2D. New, reliable biomarkers are therefore needed. MicroRNAs (miRNAs) are secreted into the circulation from cells of various tissues proportional to local disease severity. Serum miRNA-classifiers were recently found to discriminate T2D women with and without prevalent fragility fractures with high specificity and sensitivity (AUC > 0.90). However, the association of circulating miRNAs with incident fractures in T2D has not been examined yet.
In 168 T2D postmenopausal women in the AGES-Reykjavik cohort, miRNAs were extracted from baseline serum and a panel of 10 circulating miRNAs known to be involved in diabetic bone disease and aging was quantified by qPCR and Ct-values extracted. Unadjusted and adjusted Cox proportional hazard models assessed the associations between serum miRNAs and incident fragility fracture. Additionally, Receiver operating curve (ROC) analyses were performed.
Of the included 168 T2D postmenopausal women who were on average 77.2 ± 5.6 years old, 70 experienced at least one incident fragility fracture during the mean follow-up of 5.8 ± 2.7 years. We found that 3 serum miRNAs were significantly associated with incident diabetic fragility fracture: while low expression of miR-19b-1-5p was associated with significantly lower risk of incident fragility fracture (HR 0.84 (95% CI: 0.71–0.99, p = 0.0323)), low expression of miR-203a and miR-31-5p was each significantly associated with a higher risk of incident fragility fracture per unit increase in Ct-value (miR-203a: HR 1.29 (95% CI: 1.12–1.49), p = 0.0004, miR-31-5p HR 1.27 (95% CI: 1.06–1.52), p = 0.009). Hazard ratios of the latter two miRNAs remained significant after adjustments for age, body mass index (BMI), areal bone mineral density (aBMD), clinical FRAX or FRAXaBMD. Women with miR-203a and miR-31-5p serum levels in the lowest expression quartiles exhibited a 2.4–3.4-fold larger fracture risk than women with miR-31-5p and miR-203a serum expressions in the highest expression quartile (0.002 ≤ p ≤ 0.039). Women with both miR-203a and miR-31-5p serum levels below the median had a significantly increased fracture risk (Unadjusted HR 3.26 (95% CI: 1.57–6.78, p = 0.001) compared to those with both expression levels above the median, stable to adjustments. We next built a diabetic fragility signature consisting of the 3 miRNAs that showed the largest associations with incident fracture (miR-203a, miR-31-5p, miR-19b-1-5p). This 3-miRNA signature showed with an AUC of 0.722 comparable diagnostic accuracy in identifying incident fractures to any of the clinical parameters such as aBMD, Clinical FRAX or FRAXaBMD alone. When the 3 miRNAs were combined with aBMD, this combined 4-feature signature performed with an AUC of 0.756 (95% CI: 0.680, 0.823) significantly better than aBMD alone (AUC 0.666, 95% CI: 0.585, 0.741) (p = 0.009).
Our data indicate that specific serum microRNAs including senescent miR-31-5p are associated with incident fragility fracture in older diabetic women and can significantly improve fracture risk prediction in diabetics when combined with aBMD measurements of the femoral neck.
Association Between FGF-23 Levels and Risk of Fracture in Women With Systemic Sclerosis
2021, Journal of Clinical Densitometry
Introduction/Background: The purpose of this study was to evaluate the association between Fracture Risk Assessment Tool (FRAX) and serum fibroblast grow factor-23 (FGF-23) levels in SSc women patients compared with healthy controls. Methodology: This cross-sectional study was performed in San Cecilio Hospital, Granada (Spain) from November 2017 to May 2019. Sixty-two women with SSc and 62 age and sex matched healthy controls were included in this study. FGF-23 serum concentration was evaluated by indirect enzyme-linked immunosorbent assay. The FRAX scoring tool was applied using the on-line calculator (www.shef.ac.uk/FRAX). Results: Even though there was no significant difference in FGF-23 levels between SSc women patients and healthy controls (78.2 ± 60.5 vs 80.3 ± 56.3 pg/mL, p = 0.662). FGF-23 levels were positively associated with FRAX index within the study group. Conclusions: This study shows that FGF-23 status is associated with FRAX index in women with SSc. FGF-23 could be a promising biomarker for detecting risk fracture in SSc women patients.
A comparison of fracture risk assessment tools
2020, Marcus and Feldman’s Osteoporosis
Intuitively, it makes more sense to intervene in patients at high absolute risk than in patients whose risk of fracture is low. Clinical risk assessment tools are intended to facilitate this discussion with patients and are based upon the premise that prediction based upon multiple risk factors is more accurate than prediction based upon a single risk factor, including bone mineral density (BMD). Easily identified clinical risk factors (such as age, sex, and previous fracture) are associated with fracture risk independently of BMD. Several fracture risk assessment tools have been developed to estimate absolute fracture risk from these clinical factors. The clinical fracture risk assessment tools which have been most studied to date include FRAX®, the QFractureScore, and the Garvan Fracture Risk Calculator. This chapter reviews the characteristics of these tools, their strengths and limitations, incorporation into clinical practice guidelines, and prospects for improvements.
Artifacts Affecting Dual-Energy X-Ray Absorptiometry Measurements
2019, AACE Clinical Case Reports
Citation Excerpt :
Fracture risk is dose-dependent, and FRAX may underestimate risk since it incorporates the equivalent of a prednisone dose of 2.5 to 7.5 mg/day. It is also difficult to quantify risk for frequent intermittent use of high-dose glucocorticoids or high-dose inhaled glucocorticoids (18). Inflammation-mediated osteoporosis poses unique challenges.
To present 3 cases in which the presence of artifacts altered the dual-energy X-ray absorptiometry (DXA) measurements of bone mineral density (BMD) in the lumbar field.
Clinical presentation and literature review.
The first patient was a 49-year-old premenopausal woman with a spinal cord stimulator implanted in her lumbar spine. The implant increased the measured BMD in the lumbar region from osteopenia to normal range. The second patient was a 56-year-old man who had a DXA scan after he was administered oral and intravenous iodine-based contrast earlier the same day. The oral contrast in the patient's colon created a dense artifact, which overlapped the lumbar spine and adjacent soft tissue. The effect almost changed his DXA diagnosis from osteoporosis to osteopenia. The third patient was a 64-year-old woman who had undergone laparoscopic adjustable gastric banding (LAGB). A part of the LAGB system adjacent to lumbar vertebra 3 was mistakenly included as part of the vertebrae by the DXA scanner, causing an increase in the measured BMD.
There are numerous artifacts that can alter DXA BMD measurement. It is important for providers who interpret DXA scans to be familiar with the potential effects of artifacts and how to adjust for their presence, since erroneous measurements can lead to incorrect decisions regarding treatment and follow-up.

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^a: Task Force of the FRAX^® Initiative: see “Appendix.”

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Position Development PaperJoint Official Positions of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX®: Executive Summary of the 2010 Position Development Conference on Interpretation and Use of FRAX® in Clinical Practice

Abstract

Introduction

Section snippets

Topic Selection

Participants

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Position Development Paper
Joint Official Positions of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX^®: Executive Summary of the 2010 Position Development Conference on Interpretation and Use of FRAX^® in Clinical Practice