Update on guidelines for osteoporosis screening

The Buzz:  Our models for osteoporosis screening are not as robust as we might think.

Citation:  “Screening for Osteoporosis:  An Update for the U.S. Preventive Services Task Force”.  Annals of Internal Medicine. 153 (2); July 20, 2010. 99-111.

Summary:  In 2002, USPSTF recommended bone density testing for women 65 or older, as well as women 60-64 with increased risk for fractures.  No recommendation was made for or against screening other women or men. This review article updates the evidence since their 2002 USPSTF guidelines. Key comments include: 

• No trials exist to establish the effectiveness and harms of osteoporosis screening in decreasing fractures, morbidity or mortality .
• The  Osteoporosis Self-Assessment Screening Tool (OST), based only on age & weight, is the simplest tool for risk stratification.  While more complex models have been validated, no model has been shown to be superior to another.
• Only 2 good quality trials evaluated DEXA scans in men and found comparable results to those in women. 
• Calcaneal Quantitative Ultrasonography (QUS) can predict fractures of femoral neck, hip and spine, but variation exists across studies and correlation with DEXA is low.
• Only 1 study evaluated the optimum screening interval for osteoporosis. Using a cohort of post-menopausal women, it found that repeating BMD up to 8 years after the initial screening did not significantly improve risk estimates for fractures.
• For women, bisphosphonates (such as alendronate, etc), parathyroid hormone (PTH), raloxifine and estrogen decreased the risk of vertebral fractures.  Bisphosphonates decreased the risk of non-vertebral fractures.  Medications were shown to be effective in patients whose BMD was -2.5 or less.   BMD > -2.5 showed a trend of decreasing risk, but was not found to be statistically significant.
• For men, only 1 study evaluated effectiveness of a medication, PTH, and found that  PTH was associated with a trend towards decreasing fractures, but was not found to be statistically significant.
• Case reports have linked serious GI events, atrial fibrillation, osteonecrosis of the jaw, severe musculoskeletal pain, and esophageal adenocarcinoma to use of bisphosphonates.  However, when the data for these adverse events were examined, the association was tentative.
• Raloxifine and estrogen have been shown to increase thromboembolic events.  Estrogen increases the risk of stroke.  Estrogen with progestin increases the risk of coronary heart disease as well as breast cancer. 

 Commentary:  No direct evidence exists that screening for osteoporosis actually improves outcomes, although indirect evidence suggests a benefit.  

By: Jennifer Young, MD