Sun11232014

Last update 09:34:07 AM EST

Back News Endocrinology Osteoporosis Recs Urge Screening for More Women

Osteoporosis Recs Urge Screening for More Women

White women have a greater osteoporotic fracture risk than women of other races or ethnicities.

Although no lower age limit was recommended, the task force noted that women as young as 50 might have a level of risk justifying screening on the basis of the type and number of risk factors.

Screening in men was mentioned, but only to state that there was insufficient evidence to make a recommendation for or against the practice.

The new recommendations update the 2002 USPSTF guidelines that recommended bone-density screening for women ages 65 and older and women ages 60 to 64 who are at increased risk for osteoporotic fractures. The earlier guidelines did not address screening in women younger than 60 or in men.

The draft recommendations issued in the summer -- based on a systematic review conducted by researchers at Oregon Health & Science University in Portland -- were open for comments from the public, which the task force considered before finalizing the document.

Many comments reported a lack of clarity about how clinicians should estimate the 10-year fracture risks in women younger than 65 to determine whether they need to be screened, and some comments requested specific recommendations about optimal screening intervals and the age at which to begin screening in men.

The task force did not find enough evidence to provide additional information on the latter two issues, but did expand the section on estimating risk.

The guidelines recommend the use of the FRAX tool, which uses easily obtainable clinical factors such as age, body mass index, parental fracture history, and tobacco and alcohol use to estimate risk.

As a baseline, the 10-year risk of osteoporotic fracture for a 65-year-old white woman with no additional risk factors is 9.3%.

The task force provided examples of younger white women who would have comparable risk:

  • A 50-year-old current smoker with a body mass index of less than 21, daily alcohol use, and parental fracture history.
  • A 55-year-old with a parental fracture history.
  • A 60-year-old with a BMI of less than 21 and daily alcohol use.
  • A 60-year-old current smoker with daily alcohol use.

The authors added that the 10-year fracture risk using the FRAX tool is generally lower in women from other races and ethnicities than in whites.

"While the USPSTF recommends using a threshold of 9.3% 10-year fracture risk to screen women ages 50 to 64 years, clinicians should also consider each patient's values and preferences and use clinical judgment when discussing screening with women in this age group," they wrote. "Menopausal status is one factor that might affect a decision about screening in this age group."

The majority of the draft recommendations remained unchanged in the final version. The key guidance included the following:

  • Although no controlled studies have evaluated the effect of screening for osteoporosis on outcomes, the benefit of treating screening-detected osteoporosis is judged to be "at least moderate" in women 65 and older and in younger women with equivalent risk on the basis of risk factors.
  • There is convincing evidence that bone-density tests -- most commonly dual-energy x-ray absorptiometry of the hip and lumbar spine and quantitative ultrasound of the calcaneus -- predict short-term risk of osteoporotic fractures in women and men.
  • Convincing evidence demonstrates that drugs -- bisphosphonates, raloxifene, estrogen, and parathyroid hormone -- can reduce the risk of fractures in postmenopausal women. There are not enough data in men.
  • The potential harms of bisphosphonates are no greater than small and of estrogen and selective estrogen receptor modulators are small to moderate.

Although the guidelines did not make a definitive recommendation regarding screening in men, the task force members noted that, assuming the relative benefits and harms of therapy in men are similar to those in women, the men most likely to benefit from screening would be those with a fracture risk equivalent to a 65-year-old white woman.

Beatrice Edwards, MD, a gerontologist at Northwestern University, said in an e-mail to MedPage Today and ABC News that men at high risk for low bone mineral density and fractures should be screened.

That would include, for example, men with COPD and prostate cancer, those who have received solid organ transplants, cancer survivors, and those on glucocorticoids.

Also in an e-mail, Murray Favus, MD, director of the bone program at the University of Chicago, said that the lack of a plan for assessing fracture risk in men is a major problem with the guidelines.

"It is time to recognize that men will continue to be neglected until reimbursement for bone-density scans is in place," he wrote, "and a first step is inclusion of management of men in the guideline."

The members of the task force report no conflicts of interest.

This article was developed in collaboration with ABC News.

Read more http://www.medpagetoday.com/Endocrinology/Osteoporosis/24399