Proposed guidelines would expand osteoporosis screening

Issue: August 2010

In a set of draft guidelines, the U.S. Preventive Services Task Force recommends women undergo bone density screening for osteoporosis at age 65 years, as well as those at increased risk for osteoporosis at any age.

This is the first proposed update since 2002, when the U.S. Preventive Services Task Force (USPSTF) recommended bone density screening for women aged 65 years and older and for those aged 60 to 64 years at increased risk for fracture. However, no recommendation was specified for screening other groups of women or men.

The draft guidelines are the result of an evidence-based review of studies and information published since the 2002 guidelines. The task force assessed the safety and efficacy of osteoporosis screening and therapies in reducing the risk for fracture; performance of risk assessment tools and bone density screening on diagnosis of osteoporosis; and favorable screening intervals.

Data were pooled from randomized controlled trials with fracture outcomes; studies of risk-assessment tools; systematic reviews; and population-based studies of bone density screenings or therapy impairment. All studies were conducted between January 2001 and December 2009.

“Although methods to identify the risk for osteoporotic fractures are available and medications to reduce fractures are effective, no trials directly evaluate screening effectiveness, harms and intervals,” the task force wrote.

The task force found evidence that risk-assessment tools predict decreased bone mineral density and fractures; DXA predicts fractures equally for men and women; and calcaneal quantitative ultrasonography predicts fractures of the femoral neck, hip or spine in men and women, but the association with DXA is low.

Further, evidence on osteoporosis therapies revealed that use of bisphosphonates, parathyroid hormone, raloxifene and estrogen decreases primary vertebral fractures in postmenopausal women. However, studies on bisphosphonates used as primary prevention in men are lacking, according to the task force.

The USPSTF invites public comment on the draft recommendations before the final statement is published. The draft is available for public comment here. The USPSTF said it will consider public comments when finalizing the updated recommendations for publication in Annals of Internal Medicine. - by Jennifer Southall

This document adds no new information. It does not note that therapies approved for the prevention and treatment of osteoporosis are only FDA approved after placebo-controlled clinical trials have demonstrated a significant reduction in osteoporosis-related fractures without a significant difference in adverse events (other than perhaps gastrointestinal effects of oral bisphosphonates). Preventive therapies for reduction in blood pressure or dyslipidemia do not have to demonstrate a protective effect on hard outcomes (stroke, myocardial infarction, congestive heart failure) before FDA approval. Reported side effects of several of these latter classes of drugs are more common and sometimes more serious than the side effects of osteoporosis therapies. The USPSTF needs to report and compare studies of the several types of therapies for prevention of adverse health outcomes. It would surprise me if the prospective, double blind, placebo-controlled trials of osteoporosis therapies are not superior to others. In clinical practice, it is not uncommon to find patients with high BP, an abnormal lipid profile and low bone mineral density. Prescribing preventive therapy for each of these to the same person is likely to decrease patient compliance with all therapies. The USPSTF needs to review the literature on each of the conditions and advise us how to best prioritize therapies. Focusing on one disease or condition is not particularly helpful.

– Michael Kleerekoper, MD
Endocrine Today Editorial Board member

Nelson HD. Annals Intern Med. 2010;153.