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Date of release: 13 August, 2018

Screening for osteoporosis: clinical implications of the USPSTF 2018 recommendations

As the world-wide population ages, it is projected that the number of persons living with osteoporosis will also increase. Osteoporosis is usually asymptomatic until a fracture occurs, and preventing osteoporotic fractures is the main goal of an osteoporosis screening strategy. Osteoporosis justifies a screening program because it is an important public health problem and effective treatments are available.



The objectives of bone mineral density (BMD) measurements are to provide diagnostic criteria, prognostic information on the probability of future fractures, and a baseline status to follow the evolution of the disease. Dual-energy X-ray absorptiometry (DXA) is the most widely used bone densitometric technique for this purpose.



All the major societies recommend the evaluation of risk factors for osteoporosis in women after the age of 50 years. There is also agreement that DXA-based screening is indicated after the age of 65 in all women not tested previously, and for all men 70 years and older. In the younger population, women less than 65 and men less than 70 years old, BMD assessment is only recommended when risk factors for low bone mass are present. These recommendations are included in the guidelines and consensus for women by the International Menopause Society and the North American Menopause Society and for both genders in the guidelines from the National Osteoporosis Foundation [2], the American College of Obstetrics and Gynecology, the International Society for Clinical Densitometry, the International Osteoporosis Foundation, the Endocrine Society [3] and the American Academy of Family Physicians. The American Association of Clinical Endocrinologists also recommends evaluating all women 50 years and older for osteoporosis risk and considering DXA testing based on clinical fracture risk profile.



The US Preventive Services Task Force (USPSTF) has recently published recommendations on screening for osteoporosis, to prevent bone fractures in adults, based on the revision of evidence on screening and treatment of osteoporotic fractures in men and women [1]. The screening population was postmenopausal women and older men with no known previous osteoporotic fracture and no known co-morbid conditions or medication use associated with secondary osteoporosis.



The USPSTF recommends screening for osteoporosis with BMD testing to prevent osteoporotic fractures in women 65 years and older (Level B recommendation), and in postmenopausal women younger than 65 years at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool (Level B recommendation).



The USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis, to prevent osteoporotic fractures in men (Level I statement – indicates insufficient evidence).



These recommendations are consistent with the 2011 USPSTF recommendations. The major change is that the USPSTF expanded its consideration of evidence related to fracture risk assessment, with or without BMD testing, and found there is still insufficient evidence on screening for osteoporosis in men.



This USPSTF recommendation applies to adults who do not have a history of fractures, do not have an increased risk of falls, and do not have other medical conditions or treatment that may cause osteoporosis (secondary osteoporosis).



The incidence of fractures in men tends to parallel that of women, but 5–10 years later, so their fracture risk rises around age 70. Fractures are more common in women; studies show 50% of women will break a bone, compared with 20% of men. But, compared with women, when men suffer a hip fracture, worst morbidity and mortality are observed.



The lack of evidence in men does not mean that men do not benefit from screening for osteoporosis. We are concerned that the USPSTF recommendation means that men who are at significant risk for osteoporotic fractures will not get adequate screening and treatment.

Sonia Cerdas Pérez


Endocrinologa, Hospital Cima, Centro de Investigacion Clínica San Agustín, San Jose, Costa Rica



    References

  1. Screening for Osteoporosis to Prevent Fractures. US Preventive Services Task Force Recommendation Statement. JAMA 2018;319:2521-31


    http://www.ncbi.nlm.nih.gov/pubmed/29946735

  2. Cosman F, de Beur SJ, LeBoff MS, et al.; National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int 2014,25:2359-81


    http://www.ncbi.nlm.nih.gov/pubmed/25182228

  3. Watts NB, Adler RA, Bilezikian JP, et al.; Endocrine Society. Osteoporosis in men: Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2012;97:1802-22


    http://www.ncbi.nlm.nih.gov/pubmed/22675062

  4. de Villiers T Should women be screened for osteoporosis at midlife? Climacteric 2018;21:239-42


    http://www.ncbi.nlm.nih.gov/pubmed/29447485

  5. Crandall CJ, Larson J, Gourlay ML, et al. Osteoporosis screening in postmenopausal women 50 to 64 years old: comparison of US Preventive Services Task Force strategy and two traditional strategies in the Women’s Health Initiative.
J Bone Miner Res 2014;29:1661-6


    http://www.ncbi.nlm.nih.gov/pubmed/24431262