FRAX-based intervention thresholds for Pakistan

H. Johansson, G. Naureen, R. Iqbal, L. Jafri, A. H. Khan, M. Umer, E. Liu, L. Vandenput, M. Lorentzon, E. V. McCloskey, J. A. Kanis, N. C. Harvey

Research output: Contribution to journalArticlepeer-review


Summary: We compared, for women in Pakistan, the utility of intervention thresholds either at a T-score ≤ − 2.5 or based on a FRAX probability equivalent to women of average body mass index (BMI) with a prior fragility fracture. Whereas the FRAX-based intervention threshold identified women at high fracture probability, the T-score threshold was less sensitive, and the associated fracture risk decreased markedly with age. Purpose: The fracture risk assessment algorithm FRAX® has been recently calibrated for Pakistan, but guidance is needed on how to apply fracture probabilities to clinical practice. Methods: The age-specific 10-year probabilities of a major osteoporotic fracture were calculated in women with average BMI to determine fracture probabilities at two potential intervention thresholds. The first comprised the age-specific fracture probabilities associated with a femoral neck T-score of − 2.5. The second approach determined age-specific fracture probabilities that were equivalent to a woman with a prior fragility fracture, without bone mineral density (BMD). The parsimonious use of BMD was additionally explored by the computation of upper and lower assessment thresholds for BMD testing. Results: When a BMD T-score ≤ − 2.5 was used as an intervention threshold, FRAX probabilities in women aged 50 years were approximately two-fold higher than in women of the same age but with no risk factors and average BMD. The relative increase in risk associated with the BMD threshold decreased progressively with age such that, at the age of 80 years or more, a T-score of − 2.5 was actually protective. The 10-year probability of a major osteoporotic fracture by age, equivalent to women with a previous fracture, rose with age from 2.1% at the age of 40 years to 17%, at the age of 90 years, and identified women at increased risk at all ages. Conclusion: Intervention thresholds based on BMD alone do not effectively target women at high fracture risk, particularly in the elderly. In contrast, intervention thresholds based on fracture probabilities equivalent to a ‘fracture threshold’ target women at high fracture risk.

Original languageEnglish
Pages (from-to)105-112
Number of pages8
JournalOsteoporosis International
Issue number1
Early online date20 Aug 2021
Publication statusPublished - Jan 2022
Externally publishedYes


  • Epidemiology
  • Fracture probability
  • FRAX
  • Guidelines
  • Intervention threshold
  • Osteoporosis
  • Pakistan


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