What are the bone‑density (T‑score) and FRAX 10‑year probability cut‑offs for initiating osteoporosis treatment in adults over 50 (post‑menopausal women and older men)?

Fracture Risk Cut-offs for Osteoporosis Treatment

Treatment Thresholds

Initiate pharmacologic osteoporosis treatment when FRAX indicates ≥3% 10-year hip fracture risk OR ≥20% 10-year major osteoporotic fracture risk. 1, 2, 3

For bone density T-scores alone, treatment is recommended when T-score ≤-2.5 at the femoral neck or spine (excluding secondary causes). 4

Age-Based Screening and Treatment Approach

Women ≥65 Years

• Screen all postmenopausal women ≥65 years with DXA regardless of risk factors 2
• A 65-year-old white woman with no other risk factors has a baseline 10-year risk of 9.3% for any osteoporotic fracture 5
• This baseline risk serves as the reference point for younger women's screening decisions 5

Women 50-64 Years

• Screen if FRAX score (calculated without BMD) approaches or exceeds 9.3% for major osteoporotic fracture or 1.3% for hip fracture 1, 2
• Examples of women in this age group who meet screening thresholds include: a 50-year-old current smoker with BMI <21 kg/m², daily alcohol use, and parental fracture history; a 55-year-old woman with parental fracture history; or a 60-year-old woman with BMI <21 kg/m² and daily alcohol use 5
• Menopausal status should factor into screening decisions for this age group 5

Men

• Men most likely to benefit from screening have 10-year fracture risks equal to or greater than 65-year-old white women with no additional risk factors 5
• Current evidence is insufficient to establish definitive screening recommendations for men, though the same FRAX thresholds (≥3% hip fracture or ≥20% major osteoporotic fracture) are used when screening is performed 5, 2

FRAX Calculation Requirements

The FRAX tool requires the following inputs: 1, 3

• Age, sex, body mass index (BMI) or weight and height
• Country/ethnicity
• Clinical risk factors: previous fragility fracture, parental history of hip fracture, current smoking status, alcohol consumption (≥3 units/day), glucocorticoid use, rheumatoid arthritis, secondary osteoporosis
• Femoral neck BMD T-score from DXA (optional but improves accuracy) 1

Critical Adjustments for Special Populations

Glucocorticoid Users

For patients taking prednisone >7.5 mg/day, manually adjust calculated FRAX scores by multiplying major osteoporotic fracture risk by 1.15 and hip fracture risk by 1.2. 1, 2, 3

Breast Cancer Patients

• Consider BMD testing and treatment at lower FRAX thresholds for postmenopausal women with breast cancer, as FRAX underestimates fracture risk in this population 1

Hormone Replacement Therapy Users

• Do not input current HRT use into FRAX, as the tool is designed for untreated patients 1

Risk Stratification for Treatment Selection

Once treatment thresholds are met, categorize patients by risk level: 2, 3

• Very high risk (MOF >30% or hip fracture >4.5%): Consider anabolic therapy first 2
• High risk (MOF ≥20% or hip fracture ≥3%): Antiresorptive therapy (bisphosphonates, denosumab) 2

Important Limitations and Clinical Judgment

FRAX Underestimates Risk

FRAX does not account for several important risk factors that warrant clinical judgment to adjust treatment decisions: 1, 2

• Fall history
• Number of prior fractures (only captures presence/absence)
• Frailty status
• Diabetes mellitus
• Lumbar spine BMD
• Trabecular bone score
• Dose-dependent effects of glucocorticoids beyond the adjustment factor

Racial Disparities

FRAX systematically predicts lower fracture risk for Asian, Black, and Hispanic individuals compared to White individuals with identical clinical profiles, potentially leading to undertreatment in non-White populations. 1, 2 Use clinical judgment to adjust treatment decisions in these populations.

Evidence for Treatment Benefit

Treatment with bisphosphonates in high-risk patients reduces vertebral fractures by 49% (RR 0.51) and hip fractures by 33% (RR 0.67). 2 Screening with FRAX followed by DXA for high-risk individuals reduces hip fractures by 17% (RR 0.83) and major osteoporotic fractures by 6% (RR 0.94) over 3.7-5 years. 2

Reassessment Intervals

Repeat FRAX assessment every 1-3 years for patients on glucocorticoids not receiving osteoporosis treatment, with earlier reassessment for very high-dose users. 2