estimate absolute risk when assessing risk of fracture (for example, the predicted risk of major osteoporotic or hip fracture over 10 years, expressed as a percentage)
NICE suggest that clinicians use either FRAX (without a bone mineral density [BMD] value if a dual energy X-ray absorptiometry [DXA] scan has not previously been undertaken) or QFracture, within their allowed age ranges, to estimate 10-year predicted absolute fracture risk when assessing risk of fracture
consider people to be at high risk if above the upper age limits defined by the tools (1)
interpret the estimated absolute risk of fracture in people aged over 80 years with caution, because predicted 10-year fracture risk may underestimate their short-term fracture risk (1)
measurement of BMD should not be routinely used to assess fracture risk without prior assessment using FRAX (without a BMD value) or QFracture
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
before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer) then consider measuring BMD with DXA
measure BMD to assess fracture risk in people aged under 40 years who have a major risk factor, such as history of multiple fragility fracture, major osteoporotic fracture, or current or recent use of high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer)
consider recalculating fracture risk in the future:
if the original calculated risk was in the region of the intervention threshold for a proposed treatment and only after a minimum of 2 years, or when there has been a change in the person's risk factors
when assessing risk score results then take into account that risk assessment tools may underestimate fracture risk in certain circumstances, for example if a person:
has a history of multiple fractures
has had previous vertebral fracture(s)
has a high alcohol intake
is taking high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer)
has other causes of secondary osteoporosis
causes of secondary osteoporosis include
endocrine (hypogonadism in either sex including untreated premature menopause and treatment with aromatase inhibitors or androgen deprivation therapy; hyperthyroidism; hyperparathyroidism; hyperprolactinaemia; Cushing's disease; diabetes),
gastrointestinal (coeliac disease; inflammatory bowel disease; chronic liver disease; chronic pancreatitis; other causes of malabsorption),
rheumatological (rheumatoid arthritis; other inflammatory arthropathies),
immobility(due for example to neurological injury or disease)
also consider that fracture risk can be affected by factors that may not be included in the risk tool, for example living in a care home or taking drugs that may impair bone metabolism (such as anti-convulsants, selective serotonin reuptake inhibitors, thiazolidinediones, proton pump inhibitors and antiretroviral drugs
Notes:
FRAX, the WHO fracture risk assessment tool, can be used for people aged between 40 and 90 years, either with or without BMD values, as specified
QFracture can be used for people aged between 30 and 84 years. BMD values cannot be incorporated into the risk algorithm
An intervention threshold is the level of risk at which an intervention is recommended
Add information to this page that would be handy to have on hand during a consultation, such as a web address or phone number. This information will always be displayed when you visit this page