Abstract Background/Aims FRAX estimates the 10-year probability of major osteoporotic and hip fractures, with the National Osteoporosis Guideline Group (NOGG) defining intervention thresholds for initiating osteoporosis treatment. The intervention threshold corresponds to the fracture probability of a woman of the same age with a prior fragility fracture. NOGG further categorises patients as “very high risk” when their FRAX-based fracture probability exceeds the intervention threshold by at least 60%. In the UK, most DEXA centres report FRAX scores using default UK country settings, which may lead to misclassification of fracture risk in individuals from other ethnic backgrounds, potentially resulting in inappropriate treatment decisions. Objective: To evaluate the impact of applying ethnicity-specific FRAX calculations and intervention thresholds on fracture risk classification in South Asian patients compared to standard UK settings. Methods We retrospectively reviewed DEXA scan results of patients with South Asian ethnicity who had FRAX in our centre between February 2024 to May 2024. Fracture risk categorisation was recalculated using ethnicity-appropriate FRAX and corresponding intervention thresholds based on NOGG principles. Patients were classified as low risk (below intervention threshold), high risk (above intervention threshold), or very high risk (exceeding intervention threshold by ≥ 60%) using both UK and South Asian thresholds. Reclassification rates were analysed to identify potential misclassification. Results We identified 139 South Asian patients who had bone density assessment in the study period. Mean age was 62.3 ± 11.1 years, mean BMI: 27.5 ± 5.24 kg/m2. Prevalence of risk factors accounted in FRAX calculator is as below. Specific risk factors included prior fracture (n = 49), rheumatoid arthritis (n = 37), corticosteroid use (n = 19), secondary osteoporosis (n = 9), smoking (n = 9) and parental history of fracture (n = 4. 56 had one, 26 had two, and 4 had three or more risk factors. Additional risk factors included falls (n = 8) and aromatase inhibitors (n = 20). When FRAX was recalculated using ethnicity-specific settings and South Asian intervention thresholds, significant reclassification occurred. Of 103 patients initially classified below the UK intervention threshold (low risk), 3 (2.9%) were reclassified as above the South Asian intervention threshold, suggesting potential undertreatment. More notably, of 36 patients initially classified above the UK intervention threshold (high or very high risk), 9 (25%) were reclassified below the South Asian intervention threshold, indicating potential overtreatment. Risk category concordance varied substantially, with considerable reclassification when ethnicity-appropriate thresholds were applied. Conclusion Application of UK-based FRAX calculations and intervention thresholds to South Asian patients leads to substantial misclassification of fracture risk. Up to one-quarter of South Asian patients may be unnecessarily recommended pharmacological treatment when ethnicity is not accounted for in fracture risk assessment. Conversely, a small proportion may be undertreated. These findings highlight the critical importance of applying ethnicity-specific FRAX calculations and intervention thresholds to ensure appropriate treatment decisions. Disclosure N. Naina: None. J. Bradley: None. H. Muhammed: None. H. Sapkota: None. S. Venkatachalam: None.
Naina et al. (Wed,) studied this question.