A recent review by Nelson and colleagues for the US Preventive Services Task Force  updates evidence on screening for osteoporosis since the 2002 report by the same group. The purposes of the review were to determine: the effectiveness and harms of osteoporosis screening in reducing fractures for men and postmenopausal women without known previous fractures; the performance of risk assessment instruments and bone measurement tests in identifying persons with osteoporosis; optimal screening intervals; and the efficacy and harms of medications to reduce primary fractures. The data sources are the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews (through the fourth quarter of 2009), and MEDLINE (January 2001 to December 2009). The study selection included randomized, controlled trials of screening or medications with fracture outcomes published in English, performance studies of validated risk-assessment instruments and systematic reviews and population-based studies of bone measurement tests or medication harms.
The main conclusions of the study are:
(1) Several risk-assessment instruments have been developed and validated. They are modest predictors of low bone density or fracture. Simple models predict as well as complex ones and none demonstrates superiority over the others.
(2) Dual X-ray absorptiometry (DXA) is not a perfect predictor of fractures but, for each standard deviation reduction in femoral neck bone mineral density (BMD), the hazard ratio for various fracture outcomes increases to similar levels for men and women.
(3) Calcaneal ultrasound predicts fractures of the femoral neck, hip, or spine, although variation exists across studies and correlation with DXA is low. The clinical application is unknown.
(4) No studies addressing the frequency of follow-up DXA examinations were found. A single study found that repeating a BMD measurement up to 8 years after an initial measurement does not significantly improve predictive performance for non-vertebral, hip, or vertebral fractures.
(5) In women, bisphosphonates, PTH, raloxifene and estrogen reduce vertebral fractures. Bisphosphonates reduce non-vertebral fractures only in sensitivity analyses. Medications are effective for BMD [i]T[/i]-scores of -2.5 or less.
(6) Serious gastrointestinal events, atrial fibrillation, osteonecrosis of the jaw, severe musculoskeletal pain and esophageal cancer have been reported for bisphosphonates, but the incidence and degree of risk are difficult to estimate for those using them for prevention; raloxifene and estrogen increase thromboembolic events; estrogen increases stroke; and estrogen with progestin increases coronary heart disease and breast cancer.
Tobie de Villiers
Consultant Gynaecologist, Panorama MediClinic, Cape Town, South Africa
Nelson HD, Haney EM, Dana T, et al. Screening for osteoporosis: an update for the U.S. Preventive Services Task Force. Ann Intern Med 2010;153:99-111.