John A. Eisman
The FRAXÒ algorithm represented a major step forward in absolute fracture risk assessment. It took advantage of globally derived information to predict fracture risk that used that as the basis for rational treatment recommendations for a large proportion of the international community. The extrapolation of FRAXÒ to different regional and geographic criteria has been based on two sets of data that can be obtained with relatively high accuracy; these being regional age-adjusted hip fracture and mortality rates. Other fracture risk calculators that have been proposed and validated in other cohorts, including the Garvan FractureRiskCalculator that we developed from the Dubbo Osteoporosis Epidemiology Study data. This differs from FRAXÒ in that it predicts hip fractures and a range of other fragility fractures as outcomes and includes falls risk as an important fracture risk factor. However it does not include other clinical risks that are included in the FRAXÒ algorithm, including diet, smoking and glucocorticoid use amongst others. Since fragility fractures are associated with premature mortality, our work has been focussing on considering the combined risk of initial or recurrent fracture and premature mortality together. As only individuals who are at risk of fracture or other adverse events can benefit from any intervention, identifying individuals at high risk of such adverse outcomes will underpin rational decisions for intervention. Another other major step forward that is yet to take place is randomised controlled interventional studies of novel agents being based on selection of individuals at high absolute risk. This next stage of the validation of treatments based on absolute fracture risk assessment is critical. The future involves more accurate prediction of risk and then selection amongst treatments, validated in specific studies based on such risk selection. This would provide a rational basis for cost-effective osteoporosis risk management.