Fracture outcomes were available over a 10-year time frame. There was an approximately 10 % change in fracture risk for each unit of T-score discordance [87, 88]. On this basis, the authors propose that the clinician may ‘Increase/decrease FRAX estimate for a major fracture by one-tenth for each rounded T-score difference between the Lonafarnib lumbar spine and femoral neck’. Assessment of risk At present, there is no universally accepted policy for population screening in Europe to identify patients with osteoporosis or those at high risk of fracture. With the

increasing development of effective agents and price reductions, this view may change, particularly for elderly people. In the absence of such policies, patients are identified opportunistically using a case Sapitinib finding strategy on the finding of a previous fragility fracture or the presence of significant risk factors. The risk factors that are used for clinical assessment, summarised in Table 5, may be used, but in principle, any risk factor that alerts the physician to the possibility of osteoporosis is a candidate. Examples are height loss, thoracic kyphosis and the many other less well characterised causes of secondary osteoporosis. A general approach to risk assessment is shown in Fig. 4 [89]. The process begins with the assessment of fracture probability and the categorization of fracture risk on the basis of age, sex, BMI and the clinical risk factors.

On this information alone, some patients at high risk may be considered for treatment without recourse to BMD testing. For example, many guidelines in Europe [1, 47, 89–98] recommend FHPI mw treatment in the absence of information on BMD in women with a previous fragility fracture (a prior vertebral or hip fracture in North America) [84, 99]. Many physicians would also perform a BMD test, but frequently, this is for reasons other than to decide on intervention, for example, as a baseline to monitor treatment. There will

be other instances where the probability is so low that a decision not to treat can be made without BMD. Thus, not all individuals check require a BMD test. The size of the intermediate category in Fig. 4 will vary in different countries. In countries that provide reimbursement for DXA, this will be a large category, whereas in a large number of countries with limited or no access to densitometry, the size of the intermediate group will necessarily be small. In other countries (e.g. the UK), where provision for BMD testing is sub-optimal [100], the intermediate category will lie between the two extremes. Fig. 4 Management algorithm for the assessment of individuals at risk of fracture [89] with kind permission from Springer Science and Business Media Intervention thresholds The use of FRAX in clinical practice demands a consideration of the fracture probability at which to intervene, both for treatment (an intervention threshold) and for BMD testing (assessment thresholds).