Guidelines issued for screening, treatment of postmenopausal osteoporosis

To prevent and properly treat osteoporosis, the American Association of Clinical Endocrinologists (AACE) and the U.S. 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 U.S. Preventive Services Task Force (USPSTF) to update its guidelines on osteoporosis for the first time since 2002. The recommendations were published online in the Annals of Internal Medicine.

Suggestions for screening

In their respective statements, AACE and 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,” Nelson B. Watts, MD, MACE, chair of the AACE Osteoporosis Task Force, stated in a press release. “Right now, less than one-third of the cases are diagnosed, and only one-seventh of women in the U.S. with osteoporosis receive treatment.”

Based on current evidence, AACE and the USPSTF recommend screening for women older than 65 years and younger women with heightened risk for fractures. To determine the threshold for elevated risk, both task forces endorse using the fracture risk assessment tool (FRAX) — a tool developed by the World Health Organization 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 DXA serving as the gold standard for measurement.

The AACE task force and USPSTF said other technologies, including quantitative CT of central and peripheral sites, quantitative ultrasonometry, radiographic absorptiometry and single-energy X-ray absorptiometry, are available, but 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 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, and 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 (Prolia, Amgen), estrogen, raloxifene (Evista, Lilly) and teriparatide (Forteo, Eli Lilly), 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 will eventually be made available at its website.

References:

• USPSTF. Ann Intern Med. Published online ahead of print: Jan. 17, 2011.
• Watts NB. Endocr Pract. 2010;16:1-37.

Disclosure: Watts has no relevant financial disclosures.