AACE, USPSTF issue recommendations for osteoporosis screening, treatment in postmenopausal women

To prevent and properly treat osteoporosis, the American Academy of Clinical Endocrinologists and the US Preventive Services Task Force recommend routine screening for the disease in women aged older than 65 years and younger postmenopausal women at high risk for fractures.

“More than 10 million Americans have osteoporosis, and more than 34 million others have low bone mass and are therefore at increased risk for developing osteoporosis and for fracturing,” the AACE Osteoporosis Task Force wrote. “About 80% of these subjects are women, most of them menopausal.”

Further, the problem is growing, the task force noted. Between 2005 and 2025, researchers estimate that the number of osteoporosis-related fractures will increase from 2 million to 3 million, with associated costs also escalating from $17 billion to $25 billion.

This surge in statistics prompted AACE to produce recommendations, published in Endocrine Practice, outlining ways to prevent, screen for, diagnose and treat osteoporosis.

Similarly, these rising numbers also inspired the US Preventive Services Task Force (USPSTF) to update its guidelines on osteoporosis for the first time since 2002. The recommendations were published online today in the Annals of Internal Medicine.

Suggestions for screening

In their respective statements, both AACE and the USPSTF highlighted the importance of early detection.

“We have used the best evidence to draft these guidelines, taking into consideration the economic impact of the disease and the need for efficient and effective evaluation and treatment of postmenopausal women with osteoporosis,” chair of the AACE Osteoporosis Task Force Nelson B. Watts, MD, MACE, said in a press release. “Right now, less than one-third of the cases are diagnosed and only one-seventh of women in the US with osteoporosis receive treatment.”

Based on current evidence, AACE and the USPSTF recommend screening for women aged older than 65 years and younger women with heightened risk for fractures. To determine the threshold for elevated risk, both task forces endorse using FRAX — a tool developed by WHO that allows physicians to take into account certain risk factors, such as BMI, smoking, parental fracture history and daily alcohol intake — when examining a patient.

The AACE guidelines define osteoporosis as the presence of a hip or spine fracture in a patient with no other bone conditions. In those without fractures, however, bone density T-scores of –2.5 or less in the spine, femoral neck or total hip can be used for diagnosis, with central dual-energy X-ray absorptiometry (DXA) serving as the gold standard for measurement.

The AACE task force and the USPSTF noted that other technologies, including quantitative CT of central and peripheral sites, quantitative ultrasonometry, radiographic absorptiometry and single-energy X-ray absorptiometry, are available, but pointed out that data have not yet established standard thresholds for diagnosis.

After diagnosis and potential initiation of treatment, DXA should be performed every 1 to 2 years and every 2 years or more after the condition stabilizes, according to the AACE recommendations. Bone mineral density should also be monitored and bone turnover markers can be used to assess certain patients’ progress.

Prevention, treatment: One and the same?

Simple lifestyle choices can both prevent bone loss and treat osteoporosis, according to the AACE task force. Sufficient intake of calcium and vitamin D, using supplements if needed, substantially protects against bone loss as does maintaining adequate protein intake after diagnosis.

Additionally, stopping smoking and curbing caffeine and alcohol use significantly cut risk for fractures, the guidelines state. Participating in at least 30 minutes of weight-bearing exercise daily can also stave off osteoporosis onset while those already diagnosed with the disease may benefit from similar, although less intense, physical activity.

Certain patients, however, also qualify for pharmacological treatment. Physicians should use FDA-approved medications, such as bisphosphonates, calcitonin, denosumab, estrogen, raloxifene and teriparatide, according to the AACE guidelines, although certain unapproved agents with strong evidence backing their efficacy and safety for treatment of osteoporosis may be beneficial for patients who do not respond well to the recommended drugs or have other medical problems complicating therapy.

In its guidelines, the USPSTF also came to similar conclusions regarding these treatments, but reserved discussion of prevention methods for a separate document that can be found at its website in the future.

For more information:

• Bilezikian JP. Endocr Pract. 2010;16(Suppl 3).
• USPSTF. Ann Intern Med. Published ahead of print: Jan. 17, 2011.

Disclosures: Dr. Watts reports no relevant financial disclosures.

The new AACE guidelines for the diagnosis and treatment of postmenopausal osteoporosis are more than just guidelines. This publication covers the entire topic from cause to diagnosis and treatment. It provides useful definitions of what is successful treatment and explains when to stop treatment. The guidelines follow the levels of evidence format, which helps the practicing endocrinologist decide which approach is best when there are choices. The guidelines also explain the proper use of bone marker tests and emphasize the importance of preventing falls. There is also mention of the emerging concept that osteoporosis is most likely important in causing high impact fractures as well as low impact fractures. What are missing intentionally are discussions about bone disease in men and young women and children because they are beyond the scope of this publication. Because of the timing of the writing of this paper, there is nothing on the recent controversy about lower vitamin D doses and concern about calcium supplements and cardiovascular disease.

Nevertheless, for its stated intention — guidelines for the diagnosis and treatment of postmenopausal osteoporosis — this is an extraordinary work, written by authorities in the field. It should be required reading for all practitioners who see patients with osteoporosis.

– Donald A. Bergman, MD
Endocrine Today Editorial Board Member

Disclosures: Dr. Bergman reports no relevant financial disclosures.

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