A new, user-friendly platform for the freely available online FRAX^® calculator now hosts the beta version of FRAXplus^®, an optional extra that illustrates how fragility fracture risk probabilities can be modified for recency of prior fracture, exposure to higher dose oral glucocorticoids, duration of Type 2 diabetes mellitus, Trabecular Bone Score (TBS), recent falls history, concurrent data on lumbar spine BMD and Hip axis length.

FRAX^® is the most widely used online fracture risk assessment tool to estimate the individualized probability of hip fracture and major osteoporotic fracture. It integrates well-validated risk factors for fragility fracture with or without the use of bone mineral density, calibrated according to the country-specific epidemiology of hip fracture and mortality. FRAX^® is available for 78 countries or territories and in 35 languages, covering more than 80% of the world’s population. It is incorporated into approximately 80 osteoporosis management guidelines worldwide. 

Professor Eugene McCloskey MD, Professor of Adult Bone Diseases, Department of Oncology and Metabolism, University of Sheffield Medical School, UK, and co-developer of FRAX^® stated: 

“Notwithstanding FRAX’s unique strengths as confirmed in multiple studies since its launch in 2008, we have received many requests to refine or add further detail on fracture risk arising from existing FRAX variables and additional risk factors. The launch of a new and more user-friendly FRAX platform has given us the opportunity to introduce FRAXplus^® which now gives clinicians the opportunity to explore the impact of this additional information for individual patients with specific risk factors.”

The following adjustments are currently available on FRAXplus^®:

• Recency of osteoporotic fracture: The risk of a recurrent fragility fracture is particularly high immediately following a fracture. FRAXplus^® provides adjustments to FRAX-based fracture probabilities accounting for the site of a recent fracture. [1]
• High exposure to oral glucocorticoids: Moderate doses of glucocorticoids (2.5-7.5mg prednisolone daily or equivalent) are the assumed exposure in the FRAX calculation. For high doses (>7.5 mg daily), MOF probabilities are upward revised by about 15% and hip fracture probabilities by 20. FRAXplus^® gives a more accurate adjustment based on empirical data. [2]
• Type 2 diabetes mellitus: FRAX^® underestimates fracture risk in patients with type 2 diabetes. Although a simple ‘yes’ entered in the standard rheumatoid arthritis input to FRAX will adjust fracture probability, FRAXplus^® incorporates a further adjustment for the duration of Type 2 diabetes mellitus which also influences fracture risk. [3] 
• Information on Trabecular Bone Score (TBS): The Trabecular Bone Score (TBS) is derived from the texture of the DXA image at the lumbar spine and provides an index of bone microarchitecture. A low TBS is associated with an increased risk of fracture independent of FRAX and femoral neck BMD. FRAXplus^® provides access to a validated adjustment. [4]
• Falls history: A history of falls is associated with increased hip and MOF fracture risk. FRAX^® currently assumes an average exposure to falls in the last year. Adjustments for a history of 0, 1, 2 and 3 or more falls in the previous year have been derived from an analysis within the Manitoba cohort and implemented within FRAXplus^®. [5]
• Hip axis length (HAL): Longer than average hip axis length (HAL) is associated with an increase in hip fracture risk. Conversely, shorter than average length is associated with a lower risk. FRAXplus^® enables an adjustment of FRAX hip fracture probability for the measured HAL.
• Concurrent data on Lumbar Spine BMD: Major discordances between lumbar spine (LS) and femoral neck (FN) BMD T-scores are relatively uncommon but may enhance the assessment of major osteoporotic fracture (MOF) risk where they exist. Generally, a much higher LS T-score than FN T-score will lower MOF, and vice versa. FRAXplus^® allows easy incorporation of this discordance where required. [6]

Professor McCloskey added:

“Clinicians using FRAXplus^® (beta version) should note that, as there is no evidence base available to inform on the accuracy of multiple adjustments, a pragmatic approach is to make any adjustment for the most dominant factor, i.e., that which is likely to have the greatest clinical relevance for the estimated probability.”

In addition to FRAX score adjustments, FRAXplus^® offers many helpful features that are accessible via 'My FRAX': User data can be inserted and managed to save time for future use; results, scores and variables are saved in the user's personal account for further use and to easily access a history of activities and results; results can be easily exported in a pdf file to facilitate sharing and to avoid any loss of data; results can be easily shared by email; and automatic synchronisation between various devices such as cell phones, tablets and computers is possible. While the online FRAX^® calculator remains freely accessible, credits must be purchased in order to use FRAXplus^®, with proceeds assigned to support the further development of the FRAX^® tool. Free credits are offered when creating a new account and reduced rates are applicable for low and lower-middle income economies according to the World Bank Country Classification. 

Professor John Kanis, Honorary President of the International Osteoporosis Foundation (IOF) and co-developer of FRAX^®, noted:
“FRAX has been shown to be a robust assessment tool with extensive uptake in national and international guidelines. Indeed, it is now established as the standard global tool for fragility fracture risk assessment, accessible by countless healthcare professionals around the world to use in their clinical practice. With the availability of the beta version of FRAXplus^® we offer clinicians the possibility to further refine risk prediction and to optimize the identification of those at highest fracture risk. It is so important that these high-risk patients go on to receive appropriate therapy to reduce their risk of suffering debilitating fragility fractures in the future.”

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About FRAX^®
FRAX^® is a simple calculation tool that integrates clinical information in a quantitative manner to predict a 10-year probability of major osteoporotic fracture for both women and men in different countries. The tool was developed at the Centre for Metabolic Bone Diseases, University of Sheffield, UK in collaboration with international researchers. It assists primary health-care providers to better target people in need of interventions to reduce fracture risk, thus improving the allocation of health-care resources towards patients most likely to benefit from treatment. The FRAX calculator, freely accessible for use online, is available for 75 countries and in 35 languages. It is the most widely used risk assessment tool, incorporated into more than 80 national and regional guidelines worldwide. 

FRAX^® Calculation Tool (in English only): https://www.fraxplus.org/calculation-tool
FRAX^® Calculation Tool (multilanguage platform): https://frax.shef.ac.uk/FRAX/
FRAXplus^®: https://www.fraxplus.org/frax-plus 
FRAX^® Desktop: https://www.frax-tool.org/  

“the updated FRAX® website was developed with the support of an unrestricted grant from Amgen”

About IOF
The International Osteoporosis Foundation (IOF) is the world's largest nongovernmental organization dedicated to the prevention, diagnosis and treatment of osteoporosis and related musculoskeletal diseases. IOF members, including committees of scientific researchers as well as more than 315 patient, medical and research societies, work together to make fracture prevention and healthy mobility a worldwide heath care priority. www.osteoporosis.foundation   @iofbonehealth

References
[1] Kanis, J.A., Johansson, H., Harvey, N.C. et al. Adjusting conventional FRAX estimates of fracture probability according to the number of prior falls in the preceding year. Osteoporos Int 34, 479–487 (2023). https://doi.org/10.1007/s00198-022-06633-2
[2] Kanis, J.A., Johansson, H., Oden, A. et al. Guidance for the adjustment of FRAX according to the dose of glucocorticoids. Osteoporos Int 22, 809–816 (2011). https://doi.org/10.1007/s00198-010-1524-7
[3] Leslie, W.D., Johansson, H., McCloskey, E.V. et al. Comparison of Methods for Improving Fracture Risk Assessment in Diabetes: The Manitoba BMD Registry. J Bone Miner Res 33,  1923–1930 (2018). https://doi.org/10.1002/jbmr.3538
[4] McCloskey, E.V., Odén, A., Harvey, N.C, et al. A meta-analysis of Trabecular Bone Score in fracture risk prediction and its relationship to FRAX. J Bone Mineral Res 31, 940-948 (2016).
[5] Kanis, J.A., Johansson, H., Harvey, N.C., et al. Adjusting conventional FRAX estimates of fracture probability according to the number of prior falls in the preceding year. Osteoporos Int, 34, 479-487 (2023).
[6] Johansson, H., Kanis, J.A., Oden, A., et al. Impact of femoral neck and lumbar spine BMD discordances on FRAX probabilities in women: a meta-analysis of international cohorts. Calcif Tissue Int, 95, 428-435 (2014).