Official Positions for FRAX® Clinical Regarding International Differences

Osteoporosis is a serious worldwide epidemic. Increased risk of fractures is the hallmark of the disease and is associated with increased morbidity, mortality and economic burden. FRAX (R) is a web-based tool developed by the Sheffield WHO Collaborating Center team, that integrates clinical risk factors, femoral neck BMD, country specific mortality and fracture data and calculates the 10 year fracture probability in order to help health care professionals identify patients who need treatment. However, only 31 countries have a FRAX (R) calculator at the time paper was accepted for publication. In the absence of a FRAX (R) model for a particular country, it has been suggested to use a surrogate country for which the epidemiology of osteoporosis most closely approximates the index country. More specific recommendations for clinicians in these countries are not available. In North America, concerns have also been raised regarding the assumptions used to construct the US ethnic specific FRAX (R) calculators with respect to the correction factors applied to derive fracture probabilities in Blacks, Asians and Hispanics in comparison to Whites. In addition, questions were raised about calculating fracture risk in other ethnic groups e.g., Native Americans and First Canadians. In order to provide additional guidance to clinicians, a FRAX (R) International Task Force was formed to address specific questions raised by physicians in countries without FRAX (R) calculators and seeking to integrate FRAX (R) into their clinical practice. The main questions that the task force tried to answer were the following: 1. What is the evidence supporting ethnic and sex specific adjustments for fracture incidence rates in Blacks, Hispanics and Asians? 2. What data exist for other groups, e.g., Native Americans, First Nations Canadians? 3. Are there secular changes in fracture rates? 4. What are the requirements for the construction of a FRAX (R) calculator? And what are the desirable/optimal characteristics of the data? 5. What do I do if my country does not have a FRAX (R) calculator? The Task Force members conducted appropriate literature reviews and developed preliminary statements that were discussed and graded by a panel of experts at the ISCD-IOF joint conference. The statements approved by the panel of experts are discussed in the current paper.