DEFINING IMMINENT RISK USING FRAX SCORE MULTIPLIERS FOR PATIENTS WITH RECENT NON-HIP FRAGILITY FRACTURES

The widely used Fracture Risk Assessment Tool (FRAX) estimates a 10-year probability of major osteoporotic fracture (MOF) using age, sex, body mass index, and seven clinical risk factors, including prior fracture history. Prior fracture is binary in FRAX, although it is now clear that prior fractures affect future MOF risk differently depending on fracture recency and site. Risk of MOF is highest in the first two years following a fracture – this is defined as imminent risk. Therefore, the FRAX tool may underestimate true fracture risk, resulting in missed opportunities for earlier osteoporosis management. To address this, multipliers based on age, sex, and fracture type may be applied to baseline FRAX scores for patients with recent fractures. Adjusted FRAX estimates may enable earlier pharmacologic treatment and other risk reduction strategies. This study aimed to report the effect of multipliers on conventional FRAX scores in patients with recent non-hip and non-vertebral fragility fractures.  After obtaining Research Ethics Board approval, both standard and multiplier-adjusted FRAX scores were calculated for patients included in our outpatient Fracture Liaison Service who were 50 years or older and had experienced a distal radius or proximal humerus fracture between June 2020 and May 2022. Exclusion criteria consisted of patients under 50 years old, or hip or vertebral fractures. Age- and sex-based FRAX multipliers for recent distal radius and proximal humerus fractures described by McCloskey et al. (2021) were applied to conventional FRAX scores. Low, intermediate, and high-risk of MOF was defined as less than 10%, 10–20%, and greater than 20%, respectively. Data are reported as mean for continuous variables and as proportions for categorical variables. Paired samples t-tests were used to compare FRAX scores pre- and post-modifier adjustment. A total of 142 patients with an average age of 65 years (range = 50–97) were included. The majority of patients were female 90.1%, with 75.4% sustaining distal radius fractures and 24.6% sustaining proximal humerus fractures. In the distal radius group, the average MOF risk significantly increased from pre-multiplier (17.2) to post-multiplier adjustment (21.0; p<0.05). Seventeen percent of patients in the distal radius group moved from intermediate to high 10-year fracture risk after multiplier adjustment. Average FRAX scores significantly increased in the humerus group from before (16.1) to after multiplier adjustment (23.0; p <0.01), with 28.6% of patients moving from an intermediate risk to a high-risk score. Multiplier adjustment produces a clinically significant increase in conventional FRAX scores in some patients with recent non-hip fragility fractures. Twenty-eight percent of patients with humerus fractures and 17% of patients with distal radius fractures moved from intermediate to high- risk of MOF after multiplier adjustment, now meeting criteria for pharmacologic management. Using the modified FRAX score as a clinical decision-making tool in patients with recent fragility fractures may guide earlier initiation of anti-resorptive therapies and reduce the risk of future osteoporotic fractures.

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