by Todd Neale
Postmenopausal women of any age with a 10-year fracture risk equal to or greater than that of a 65-year-old woman and no other osteoporosis risk factors should be screened for the disease, according to draft guidelines from the U.S. Preventive Services Task Force (USPSTF).
The 2002 USPSTF guidelines recommended routine screening only for women ages 65 and older, as well as women ages 60 to 64 with an increased risk for osteoporotic fractures. The current guidelines contain no recommendation for or against screening in younger women.
An additional change from the 2002 guidelines is a mention of men, albeit only to say that evidence is insufficient to assess the balance of benefits and harms of screening in older men.
The updated guidance is still in draft form and will be available on the Agency for Healthcare Research and Quality’s website for four weeks to receive public comments. After consideration of feedback, the final recommendations will be released.
The accompanying evidence review, conducted by Heidi Nelson, MD, MPH, of the Oregon Evidence-Based Practice Center, and colleagues, was published online in the Annals of Internal Medicine. This process is a change from past guidelines, which were released in their final form with the evidence review.
According to estimates from the U.S. Surgeon General, as many as 50% of Americans older than 50 years will be at risk for osteoporotic fractures during their lifetimes. This translates to 12 million people with osteoporosis by 2012, according to background information in the review. Rates of osteoporosis among women are higher than among men, and rates are also higher for whites. Among all groups, rates rise with increasing age, the authors noted.
Ethel S. Siris, MD, director of the Toni Stabile Osteoporosis Center at Columbia University Medical Center and New York-Presbyterian Hospital, said the updated evidence review does not change much from 2002.
“You test people because of their age,” Siris wrote in an e-mail to MedPage Today. “You test because of other risk factors that put them at high risk of fractures (family history, steroids, unhealthy eating behaviors, etc.).”
“As physicians, if you identify someone at high risk and you and the patient agree that it’s okay to test and treat, then that’s what you should do,” she added.
The evidence review evaluated studies that have been completed since 2002 to answer several questions posed by the USPSTF, including whether screening for osteoporosis improves outcomes.
Nelson and her colleagues found neither studies to answer that question nor data directly addressing harms or appropriate intervals for screening.
“This study may be interpreted as there’s no need to screen,” said Siris, who was not involved in the study. “But what’s really important is that there’s a lot of indirect evidence … that if we give people the test and we treat them, they will get better.”
The evidence review supported Siris’ assertion.
There were numerous studies showing that various risk-assessment instruments and bone-measurement tests — including dual X-ray absorptiometry and quantitative ultrasound of the calcaneus — were able to predict the risk of osteoporotic fractures. None, however, evaluated whether testing resulted in improved outcomes.
The review cited several trials showing that bisphosphonates, raloxifene, estrogen, and parathyroid hormone were all effective for primary prevention of vertebral fractures in women. However, studies in men were lacking.
In general, these medications were reported to carry a low risk of harm.
Bisphosphonates were inconsistently associated with serious adverse events, although serious gastrointestinal events, atrial fibrillation, osteonecrosis of the jaw, severe musculoskeletal pain, and esophageal cancer have been reported.
Raloxifene and estrogen increase thromboembolic events; estrogen has been linked to an increased risk of stroke, coronary heart disease, and breast cancer.
“The USPSTF found adequate evidence that the harms of bisphosphonates, the most commonly prescribed therapies, are no greater than small; convincing evidence indicates that the harms of estrogen and selective estrogen receptor modulators are small to moderate,” according to the draft guidelines.
Considering all of the evidence as a whole, “the USPSTF judged that the magnitude of benefit of treating screening-detected osteoporosis is at least moderate,” the guidelines stated.
In order to focus on primary prevention — the goal of screening — the review excluded trials conducted in populations where more than 20% of patients had suffered a previous osteoporotic fracture.
But excluding these trials was a major flaw of the analysis, according to Deborah Sellmeyer, MD, director of the Johns Hopkins Metabolic Bone Center.
“Exclusion of these studies resulted in exclusion of many of the major osteoporosis treatment trials, greatly limiting the data available on effectiveness of treatments,” she said in an e-mail to MedPage Today.
Nonetheless, Sellmeyer supports screening for osteoporosis, because testing is fast, painless, and relatively inexpensive, and medications that reduce fracture risk are available.
“Thus,” she said, “we should continue screening individuals who may be at increased risk for fracture with bone density testing and clinical risk factor assessment and treating those whose bone density and risk factors predict they are at increased risk for fracture.”
Todd Neale is a MedPage Today staff writer.