USPSTF Recommendations: Screening for Osteoporosis to Prevent Fractures

SUMMARY:  

The USPSTF released recommendations update for osteoporosis screening to prevent fractures (2018).  The following guidelines are based upon an assessment of benefits vs harms and does not include cost analysis.

• USPSTF Recommendations
• Clinical risk factors in postmenopausal women <65 years of age
• Clinical risk assessment tools
• Screening Tests
• Additional Related USPSTF Recommendations
• Other Professional Recommendations

USPSTF Recommendations

Women ≥ 65 years and older 

• The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures (B recommendation)
  • • Offer or provide this service
  • There is high certainty that the net benefit is substantial

Women <65 years and postmenopausal  

• The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women who are at increased risk, as determined by a formal clinical risk assessment tool (B recommendation)
  • Offer or provide this service
  • There is high certainty that the net benefit is substantial 
• The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis to prevent osteoporotic fractures in men (I statement)
  • The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service
  • Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined

KEY POINTS:  

Clinical Risk Factors in Postmenopausal Women <65 Years of Age 

• If ≥1 risk factor, “a reasonable approach” is to use a clinical risk assessment tool (see below)  
• Clinical risk factors include  
  • Parental history of hip fracture 
  • Smoking 
  • Excessive alcohol consumption 
  • Low body weight

Clinical risk assessment tools 

• In the previous guideline (2011), FRAX was the clinical risk assessment tool of choice 
  • Current (2018) guidance now includes others  
• The following tools perform similarly and are moderately accurate at predicting osteoporosis 
  • The Simple Calculated Osteoporosis Risk Estimation (SCORE) 
  • Osteoporosis Risk Assessment Instrument (ORAI) 
  • Osteoporosis Index of Risk (OSIRIS) 
  • Osteoporosis Self-Assessment Tool (OST) 
• FRAX tool (University of Sheffield) 
  • Assesses a person’s 10-year risk of fracture 
  • Includes questions about previous DXA results but not required to assess risk 

USPSTF states that one approach is to  

• Perform bone measurement testing in postmenopausal women younger than 65 years who have a 10-year FRAX risk of major osteoporotic fracture (without DXA) greater than that of a 65-year-old white woman without major risk factors 
• Example, using white woman of mean height and weight  
  • 65-year-old without major risk factors: 10-year FRAX risk of major osteoporotic fracture of 8.4% 
  • 60-year-old with a parental history of hip fracture: 10-year FRAX risk of major osteoporotic fracture of 13%  
• A particular risk factor or a certain age does not represent a particular risk threshold 
• Multiple risk factors at a younger age may indicate that the risk-benefit profile is favorable for screening with bone measurement testing

Screening Tests 

• Central DXA (most common) 
  • Measures BMD at the hip and lumbar spine 
  • Used for most professional treatment guidelines (based on entry criteria for study enrollment) 
• Peripheral DXA 
  • Measures BMD at the lower forearm and heel 
  • Due to portable device measurement, may provide access when central DXA is not available  
• Quantitative ultrasound (QUS) 
  • Evaluates peripheral sites  
  • Similar accuracy in predicting fracture risk as DXA 
  • Avoids radiation exposure 
  • Does not measure BMD and therefore prior to routine use, a conversion method to the DXA scale is needed

Additional Related USPSTF Recommendations 

• Preventing falls 
  • The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years and older at increased risk of falls  
  • Selectively offer multifactorial interventions based on circumstances of prior falls, presence of comorbid medical conditions, and the patient’s values and preferences  
  • USPSTF recommends against Vitamin D supplementation to prevent falls 
• Preventing fractures  
  • USPSTF recommends against supplementation with 400 IU or less of vitamin D and 1000 mg or less of calcium in postmenopausal women to prevent fractures 
  • The USPSTF found insufficient evidence on supplementation with higher doses of vitamin D and calcium, alone or combined, to prevent fractures in postmenopausal women, or at any dose in men and premenopausal women

Other Professional Recommendations 

• National Osteoporosis Foundation  
  • Recommends BMD testing in all women 65 years and older and all men 70 years and older 
  • Recommends BMD testing in postmenopausal women younger than 65 years and men aged 50 to 69 years based on their risk factor profile, including if they had a fracture as an adult 
• The International Society for Clinical Densitometry  
  • Recommends BMD testing in all women 65 years and older and all men 70 years and older 
  • Recommends BMD testing in postmenopausal women younger than 65 years and men younger than 70 years who have risk factors for low bone mass 
• American Academy of Family Physicians (as part of Choosing Wisely)  
  • Recommends against DXA screening in women younger than 65 years and men younger than 70 years with no risk factors 
• ACOG
  • Recommends BMD testing with DXA in postmenopausal patients 65 years and older
  • Recommends selective screening in postmenopausal women younger than 65 years who have osteoporosis risk factors as determined by  formal clinical risk assessment tool
• American Association of Clinical Endocrinologists 
  • Recommends evaluating all women 50 years and older for osteoporosis risk and considering BMD testing based on clinical fracture risk profile 
• Endocrine Society  
  • Recommends screening in men older than 70 years  
  • Recommends screening adults  
    • 50 to 69 years with significant risk factors 
    • Fracture after age 50 years

Learn More – Primary Sources:  

US Preventive Services Task Force Recommendation Statement:  Screening for Osteoporosis to Prevent Fractures

JAMA Editorial: Screening for Osteoporosis

FRAX® Fracture Risk Assessment Tool

Development and assessment of the Osteoporosis Index of Risk (OSIRIS) to facilitate selection of women for bone densitometry

Osteoporosis Self-Assessment Tool for Asians (OSTA) Research Group.  A simple tool to identify Asian women at increased risk of osteoporosis

Validation and comparative evaluation of the osteoporosis self-assessment tool (OST) in a Caucasian population from Belgium

Development and validation of the Osteoporosis Risk Assessment Instrument (ORAI) to facilitate selection of women for bone densitometry

Validation of the simple calculated osteoporosis risk estimation (SCORE) for patient selection for bone densitometry 

Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Clinical Practice Guideline

ACOG Clinical Practice Guideline1: Osteoporosis Prevention, Screening and Diagnosis

ACP Releases Guidance Update on Osteoporosis Treatment

SUMMARY:

The ACP has released an update on treatment of osteoporosis. Bone mass and changes in bone microarchitecture leads to bone fragility and risk of fracture. Osteoporosis is common, with 50% of individuals over 50 years of age at risk of fracture and can result in substantial morbidity and mortality. While osteoporosis can occur in both men and women, and the update covers all individuals, female sex is a known risk factor.  The AAFP has endorsed these recommendations.

SUMMARY OF RECOMMENDATIONS FOR WOMEN:

• Treat women with known osteoporosis to reduce hip and vertebral fractures with the following medications (Grade: strong recommendation; high-quality evidence)
  • Alendronate
  • Risedronate
  • Zoledronic acid
  • Denosumab
• Treat osteoporotic women for 5 years (Grade: weak recommendation; low-quality evidence)
• Do not monitor bone density during 5-year treatment period
• Do not use menopausal estrogen therapy (with or without progestogen) or raloxifene (Grade: strong recommendation; moderate-quality evidence)
• ≥ age 65 at high risk for osteopenic fractures (Grade: weak recommendation; low-quality evidence)
  • Base treatment on informed decision making risks and benefits

NOTE – RECOMMENDATIONS FOR MEN:

• Bisphosphonates to reduce the risk for vertebral fracture in setting of clinical diagnosis of osteoporosis (Grade: weak recommendation; low-quality evidence)

RISK FACTORS FOR OSTEOPOROSIS (Partial List):

• Clinical
  • Increasing age
  • Caucasian
  • Female
  • Low Dietary Calcium Intake
  • Underweight
  • Excessive Alcohol Intake (> 3 drinks/day)
  • Smoking
  • Fractures due to minimal trauma
• Family or personal history of fractures due to osteoporosis
• Medical History
  • Rheumatoid arthritis
  • HIV
  • Immobilization
  • Premature ovarian failure
  • Postmenopausal
  • Medications (partial list)
    • Glucocorticoids
    • Anticoagulants
    • Anticonvulsants
    • Aromatase inhibitors
    • Gonadotropin-releasing hormone agonists
    • Androgen deprivation therapy
• Clinical laboratory
  • Vitamin D deficiency

DIAGNOSIS:

• Occurrence of fragility fracture
• Decreased BMD
  • Dual-energy x-ray absorptiometry (DXA)
  • Will only predict less than 50% of fractures
  • FRAX (the World Health Organization Fracture Risk Assessment Tool) combines clinical factors with BMD testing results
  • T score of –2 indicates a BMD that is 2 SDs below the comparative norm
  • International reference standard in postmenopausal women and in men aged 50 years or older
    • Neck BMD of 2.5 SD or more < the young female adult mean

Learn More – Primary Sources:

Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women: A Clinical Practice Guideline Update from the American College of Physicians

AAFP Endorses ACP Guideline on Treating Osteoporosis

FRAX Fracture Risk Assessment Tool