Impact of country-specific FRAX assessment and intervention thresholds on treatment recommendations in South Asian patients in UK

Tony Austin; Naina; Chera Jaden Singh; Challa Hima Varsha; Salamat Ullah; Mateusz Wawaczyk; James Francis; Veena Patel; Josh Bradley; Hem Sapkota; Hafis Muhammed; Srinivasan Venkatachalam

doi:10.1530/obabs.08.P74

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Bone Abstracts (2026) 8 P74 | DOI: 10.1530/obabs.08.P74

OP2026 Poster Presentations Original Research (32 abstracts)

Impact of country-specific FRAX assessment and intervention thresholds on treatment recommendations in South Asian patients in UK

Tony Austin ¹ , Naina Naina ¹ , Jaden Singh Chera ² , Hima Varsha Challa ² , Salamat Ullah ² , Mateusz Wawaczyk ² , James Francis ² , Veena Patel ² , Josh Bradley ¹ , Hem Sapkota ¹ , Hafis Muhammed ¹ & Srinivasan Venkatachalam ¹

Author affiliations

¹The Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom; ²University Hospitals of Leicester NHS Trust, Leicester, United Kingdom

Background: The 10-year probability of major osteoporotic and hip fractures from FRAX is country-specific. The UK National Osteoporosis Guideline Group (NOGG) intervention threshold for treatment corresponds to the fracture probability of a person of the same age with a prior fragility fracture. "Very high risk" category means the fracture probability exceeds the intervention threshold by at least 60%. UK FRAX may not accurately reflect fracture-risk in patients from other countries, impacting treatment decisions.

Objective: To evaluate the impact of applying country-specific FRAX calculation and intervention thresholds on fracture-risk classification in South Asian patients.

Methods: We retrospectively reviewed DXA scans of South Asian patients from 2 centres in the Midlands, Wolverhampton (February to May 2024), and Leicester (May to June 2024). Fracture-risk was recalculated using country-specific 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 settings.

Results: We identified 239 South Asian patients (139 Wolverhampton, 100 Leicester) who had a bone density assessment in the study period. The mean age was 63.1 ± 11.4 years (204 female, 35 male). Risk factors included prior fracture (n77), rheumatoid arthritis (n54), corticosteroid use (n34), smoking (n14), parental history of fracture (n7), falls (n17) and aromatase inhibitors (n47). Of the 172 patients initially classified as below the UK intervention threshold (low risk), 4 (2.3%) were above the South Asian intervention threshold, suggesting undertreatment. More notably, of the 67 patients initially classified as above the UK intervention threshold (high or very high risk), 17 (25.4%) were below the South Asian intervention threshold, indicating potential overtreatment. There was significant discordance in risk categorisation when country-specific thresholds were applied.

Conclusion: Applying the UK-FRAX calculation and intervention thresholds to South Asian patients with Osteoporosis risks substantial misclassification. Up to one in four South Asian patients recommended pharmacological treatment for osteoporosis based on UK-FRAX may not actually need it; conversely, a small proportion risk being undertreated. Country-specific FRAX calculation and intervention thresholds ensure that osteoporosis treatment decisions are appropriate.