In an update to its 2011 recommendations, the U.S. Preventive Services Task Force recommends screening with bone measurement testing to prevent osteoporotic fractures in women aged at least 65 years and in postmenopausal, high-risk women younger than 65 years.
However, the USPSTF does not recommend osteoporosis screening in men, citing insufficient current evidence to assess the balance of benefit and harm. According to the statement: “It cannot be assumed that the bones of men and women are biologically the same, especially because bone density is affected by differing levels and effects of testosterone and estrogen in men and women. ... Men tend to experience fractures at an older age than women, when risk of comorbid conditions and overall mortality are higher; thus, the net balance of benefits and harms of screening for and treatment of osteoporosis in men is unclear.”
As previously reported by Healio.com, a draft version of these recommendations was posted for public comment from November to December 2017.
The USPSTF cited “convincing evidence” on the accuracy of bone measurement tests — including commonly used DXA, peripheral DXA and quantitative ultrasound — for detecting osteoporosis and preventing related fractures in women and men. In its review, the USPSTF found “adequate evidence” on the accuracy of clinical risk-assessment tools for identifying osteoporosis and related fractures. Recommended clinical risk-assessment tools include the Simple Calculated Osteoporosis Risk Estimation (SCORE, Merck) calculator, Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Index of Risk (OSIRIS), Osteoporosis Self-Assessment Tool (OST) and Fracture Risk Assessment Tool (FRAX). The 2011 recommendations endorsed FRAX in the younger group, but expanded the 2018 recommendation to a number of formal clinical risk-assessment tools. When determining which postmenopausal women younger than 65 years to screen with bone measurement testing, clinicians should first consider risk factors for osteoporosis such as history of hip fracture, smoking, excessive alcohol consumption and low body weight.
The USPSTF also found “convincing evidence” that available drug therapies reduce subsequent fracture rates in postmenopausal women, with “low likelihood of serious harm.” The task force did not make recommendations for drug therapies and instead recommends that treatment options be made on an individual basis.
New evidence on screening benefits, harms
Also published in JAMA is an updated evidence report and systematic review for the USPSTF on the benefits and harms of screening and treatment to prevent osteoporotic fractures in U.S. community-dwelling adults. Meera Viswanathan, PhD, from RTI International-University of North Carolina at Chapel Hill Evidence-Based Practice Center, and colleagues analyzed data from PubMed, the Cochrane Library, EMBASE and trial registries from November 2009 to October 2016 and surveilled the literature through March.
Their search turned up 168 fair-or good-quality studies that assessed screening, bone measurement tests or clinical risk assessment and pharmacologic treatment for osteoporosis among adults aged at least 40 years. One trial of 12,483 participants comparing screening vs. no screening yielded fewer hip fractures (HR = 0.72; 95% CI, 0.59-0.89), but no other significant harms or benefits of screening. The accuracy of specific bone measurement tests and clinical risk assessments showed benefit, but varied across the studies.
Evidence on osteoporosis treatment options was inconsistent. In women, treatment with bisphosphonates, parathyroid hormone, raloxifene and denosumab (Prolia, Amgen) were associated with reduced risk for vertebral fractures in nine studies. Risk for nonvertebral fractures was lower with bisphosphonates in nine studies and denosumab in one study. Denosumab was also linked to reduced hip fracture risk. Evidence was inconsistent in men, with one study showing lower risk for radiographic vertebral fractures and no studies showing reductions in clinical or hip fractures. Aside from deep vein thrombosis, bisphosphonates were not consistently linked to other reported harms, according to the report.
“In women, screening to prevent osteoporotic fractures may reduce hip fractures, and treatment reduced the risk of vertebral and nonvertebral fractures; there was not consistent evidence of treatment harms. The accuracy of bone measurement tests or clinical risk assessments for identifying osteoporosis or predicting fractures varied from very poor to good,” Viswanathan and colleagues wrote.
‘Fracture prevention is the ultimate goal’
In a related editorial, Jane A. Cauley, DrPH, distinguished professor in the department of epidemiology and associate dean for research in the Graduate School of Public Health at the University of Pittsburgh, noted that the updated recommendation statement and evidence report are “timely.”
According to current projections, 12.3 million U.S. adults older than 50 years are expected to have osteoporosis by 2020.
“Fracture prevention is the ultimate goal, and [bone mineral density] screening is an effective, low-cost, noninvasive means of identifying men and women at high risk of fracture. Yet, major deficiencies remain in BMD screening, even among women 65 years and older. Assessment of clinical risk factors is also important because individuals with the combination of low BMD and an increasing number of risk factors have the highest incidence of hip fracture. Screening must be followed with effective treatment and fall prevention among those at high risk.
“Future research should identify ways of improving BMD screening rates and to improve identification of young women (50-64 years) and older men who would benefit from BMD screening,” Cauley wrote.
Cauley JA. JAMA. 2018;doi:10.1001/jama.2018.5722.
US Preventive Services Task Force. JAMA. 2018;doi:10.1001/jama.2018.7498.
Viswanathan M, et al. JAMA. 2018;doi:10.1001/jama.2018.6537.
Disclosures: Cauley, Viswanathan and fellow authors report no relevant financial disclosures. All members of the USPSTF receive travel reimbursement and an honorarium for participating in USPSTF meetings; no other disclosures were reported.