Recommendations for osteoporosis screening are based on indirect evidence mostly obtained from studies of women, according to an update of the 2002 US Preventive Services Task Force (USPSTF) osteoporosis screening guidelines posted online July 6 and printed in the July 20 issue of the Annals of Internal Medicine.
"This review updates evidence since the 2002 [USPSTF] recommendation on osteoporosis screening," write Heidi D. Nelson, MD, MPH, from the Oregon Evidence-Based Practice Center at Oregon Health & Science University and the Women and Children's Health Research Center, Providence Health & Services in Oregon, Portland, and colleagues. "In 2002, on the basis of results of a previous review, the USPSTF recommended bone density screening for women 65 years or older and women aged 60 to 64 years at increased risk for osteoporotic fractures. They made no recommendations for or against screening postmenopausal women younger than 60 years or women aged 60 to 64 years without increased risk."
Updated Review Process/Goals
The goals of this updated review were to evaluate the efficacy and harms of osteoporosis screening in decreasing fractures for men and for postmenopausal women with no previous history of fractures, the ability of risk assessment instruments and bone measurement tests to diagnose osteoporosis, optimal screening intervals, and effectiveness and harms of medications to reduce primary fractures.
The reviewers searched the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews through the fourth quarter of 2009, MEDLINE from January 2001 to December 2009, bibliographies of retrieved articles, and Web of Science.
Inclusion criteria were English-language publications of randomized controlled trials of screening or medications with fracture outcomes, performance studies of validated risk-assessment instruments, and systematic reviews and population-based studies of tests for bone measurement or of harms from medication. Using established criteria, the reviewers rated and abstracted data on patient populations, study design, analysis, and follow-up. This review of studies published from January 2001 to December 2009 regarding osteoporosis screening found no trials of screening.
There were 14 risk-assessment instruments identified, which modestly predicted low bone density (area under the curve [AUC], 0.13 - 0.87), and 11 that modestly predicted fractures (AUC, 0.48 - 0.89). Performance of simple and complex instruments was not significantly different.
In a large trial of women performed to determine the optimal screening interval for multiple studies for osteoporosis, a second measurement of bone mineral density up to eight years after the first test did not improve the risk ratio estimates for fracture.
Ability of dual-energy x-ray absorptiometry to predict fractures was similar for men and women. Although calcaneal quantitative ultrasonography also predicted fractures, correlation with dual-energy x-ray absorptiometry was only fair.
Use of bisphosphonates, parathyroid hormone, raloxifene, and estrogen were linked to lower incidence of primary vertebral fractures for postmenopausal women, but trials were lacking in men. Relative risks for vertebral fracture for women using one of these medications vs placebo were 0.66, 0.32, 0.61, and 0.62, respectively.
For nonvertebral fractures, evidence was less convincing that these medications reduced risk. For bisphosphonates, there was a lower risk for nonvertebral fracture observed with analysis using alternative pooling methods. The only medication tested for primary fracture prevention in men with low bone density was parathyroid hormone, which was associated in one study with a trend toward lower fracture rate.
Although bisphosphonates are not consistently associated with serious adverse events, raloxifene and estrogen are associated with increased thromboembolic events, and estrogen is associated with additional adverse events.
A limitation of this review is the absence of trials, especially in men, regarding screening with fracture outcomes, screening intervals, and medications intended to prevent or lower primary fracture rate. In addition, it is difficult to apply the results of clinical trials to patient care when selection criteria are rigid and study participants are not representative of the community population, especially in older populations with comorbidities and polypharmacy that would disqualify patients from enrolling in most trials.
"Osteoporosis and osteoporosis-related fractures are common in aging men and women in the United States," the review authors write. "Fractures cause premature mortality, loss of independence and function, reduced quality of life, and substantial financial costs. Although methods to identify persons at risk for osteoporotic fractures are available and medications to reduce fractures are effective, no trials directly evaluate screening effectiveness, harms, and intervals."
The Agency for Healthcare Research and Quality supported this study. One of the study authors was supported by a career development award from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Nelson reports various financial relationships with the Agency for Healthcare Research and Quality and Merck.
Ann Int Med. Published online July 6, 2010.
Laurie Barclay, MD • Medscape Medical News © 2010 Medscape, LLC