Letters to the Editor

In Reply: DXA after menopause

Kristi Tough DeSapri, MD and Rachel Brook, MD
Cleveland Clinic Journal of Medicine August 2020, 87 (8) 457-458; DOI: https://doi.org/10.3949/ccjm.87c.08004

Thank you for your commentary on “off-label” use of FRAX to better predict fracture risk for patients (such as those with diabetes or on high-risk medications) who don’t fit neatly into the FRAX algorithm. FRAX does allow for individualized calculation of relative risk of fracture across age and hip bone mineral density. And age may indirectly incorporate risk of falls, as 25% of people over age 65 fall annually.1

With the limitations of FRAX, we must recognize that calculation tools must not replace clinical judgment and assessment of fall and fracture risk for our individual patients. Bone mineral density scanning estimates 70% of bone strength, and other factors may influence fracture risk. As Dr. Balkin mentions, the trabecular bone score and also hip geometry (bone strength based on the measurement of proximal femur) may supplement axial bone mineral density testing with central DXA to determine propensity to fracture.2

Other technologies are being developed. For example, biomechanical computed tomography uses finite element analysis to provide a virtual stress test of a patient’s bone to measure its breaking strength in newtons.

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