Purpose of review: There is an increasing recognition that the management of osteoporosis requires the characterization of fracture risk to be based on absolute risk rather than single measures such as bone mineral density (BMD). FRAX, the most widely used tool that incorporates clinical risk factors with or without BMD, was launched in 2008. This brief review addresses the development of FRAX since then and describes some of the issues that continue to be discussed as FRAX plays an increasing role in clinical practice.
Recent findings: FRAX is a platform technology that will continue to develop. High-quality updated epidemiology of fracture and mortality can lead to recalibration of models. The addition of new risk factors is complex as the process requires validation in an international setting as well as a comprehensive assessment of how such new factors interact with the existing FRAX variables. Nonetheless, clinical interpretation can be enhanced by taking into account the potential adjustments of FRAX probabilities and several of these are described.
Summary: FRAX is being incorporated in an increasing number of clinical guidelines, and assessment and intervention thresholds have been provided to instruct clinical decision-making. There is an increasing body of evidence that patients deemed at highest risk of fracture by FRAX, with or without the use of BMD, will overlap significantly with those identified by previous guidelines and will respond to appropriate osteoporosis therapy.