USPSTF Recommendations: Screening for Osteoporosis to Prevent Fractures
SUMMARY:
The USPSTF released recommendations update for osteoporosis screening to prevent fractures (2018). The following guidelines are based upon an assessment of benefits vs harms and does not include cost analysis.
- USPSTF Recommendations
- Clinical risk factors in postmenopausal women <65 years of age
- Clinical risk assessment tools
- Screening Tests
- Additional Related USPSTF Recommendations
- Other Professional Recommendations
USPSTF Recommendations
Women ≥ 65 years and older
- The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures (B recommendation)
- Offer or provide this service
- There is high certainty that the net benefit is substantial
Women <65 years and postmenopausal
- The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women who are at increased risk, as determined by a formal clinical risk assessment tool (B recommendation)
- Offer or provide this service
- There is high certainty that the net benefit is substantial
- The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis to prevent osteoporotic fractures in men (I statement)
- The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service
- Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined
KEY POINTS:
Clinical Risk Factors in Postmenopausal Women <65 Years of Age
- If ≥1 risk factor, “a reasonable approach” is to use a clinical risk assessment tool (see below)
- Clinical risk factors include
- Parental history of hip fracture
- Smoking
- Excessive alcohol consumption
- Low body weight
Clinical risk assessment tools
- In the previous guideline (2011), FRAX was the clinical risk assessment tool of choice
- Current (2018) guidance now includes others
- The following tools perform similarly and are moderately accurate at predicting osteoporosis
- The Simple Calculated Osteoporosis Risk Estimation (SCORE)
- Osteoporosis Risk Assessment Instrument (ORAI)
- Osteoporosis Index of Risk (OSIRIS)
- Osteoporosis Self-Assessment Tool (OST)
- FRAX tool (University of Sheffield)
- Assesses a person’s 10-year risk of fracture
- Includes questions about previous DXA results but not required to assess risk
USPSTF states that one approach is to
- Perform bone measurement testing in postmenopausal women younger than 65 years who have a 10-year FRAX risk of major osteoporotic fracture (without DXA) greater than that of a 65-year-old white woman without major risk factors
- Example, using white woman of mean height and weight
- 65-year-old without major risk factors: 10-year FRAX risk of major osteoporotic fracture of 8.4%
- 60-year-old with a parental history of hip fracture: 10-year FRAX risk of major osteoporotic fracture of 13%
- A particular risk factor or a certain age does not represent a particular risk threshold
- Multiple risk factors at a younger age may indicate that the risk-benefit profile is favorable for screening with bone measurement testing
Screening Tests
- Central DXA (most common)
- Measures BMD at the hip and lumbar spine
- Used for most professional treatment guidelines (based on entry criteria for study enrollment)
- Peripheral DXA
- Measures BMD at the lower forearm and heel
- Due to portable device measurement, may provide access when central DXA is not available
- Quantitative ultrasound (QUS)
- Evaluates peripheral sites
- Similar accuracy in predicting fracture risk as DXA
- Avoids radiation exposure
- Does not measure BMD and therefore prior to routine use, a conversion method to the DXA scale is needed
Additional Related USPSTF Recommendations
- Preventing falls
- The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years and older at increased risk of falls
- Selectively offer multifactorial interventions based on circumstances of prior falls, presence of comorbid medical conditions, and the patient’s values and preferences
- USPSTF recommends against Vitamin D supplementation to prevent falls
- Preventing fractures
- USPSTF recommends against supplementation with 400 IU or less of vitamin D and 1000 mg or less of calcium in postmenopausal women to prevent fractures
- The USPSTF found insufficient evidence on supplementation with higher doses of vitamin D and calcium, alone or combined, to prevent fractures in postmenopausal women, or at any dose in men and premenopausal women
Other Professional Recommendations
- National Osteoporosis Foundation
- Recommends BMD testing in all women 65 years and older and all men 70 years and older
- Recommends BMD testing in postmenopausal women younger than 65 years and men aged 50 to 69 years based on their risk factor profile, including if they had a fracture as an adult
- The International Society for Clinical Densitometry
- Recommends BMD testing in all women 65 years and older and all men 70 years and older
- Recommends BMD testing in postmenopausal women younger than 65 years and men younger than 70 years who have risk factors for low bone mass
- American Academy of Family Physicians (as part of Choosing Wisely)
- Recommends against DXA screening in women younger than 65 years and men younger than 70 years with no risk factors
- ACOG
- Recommends BMD testing with DXA in postmenopausal patients 65 years and older
- Recommends selective screening in postmenopausal women younger than 65 years who have osteoporosis risk factors as determined by formal clinical risk assessment tool
- American Association of Clinical Endocrinologists
- Recommends evaluating all women 50 years and older for osteoporosis risk and considering BMD testing based on clinical fracture risk profile
- Endocrine Society
- Recommends screening in men older than 70 years
- Recommends screening adults
- 50 to 69 years with significant risk factors
- Fracture after age 50 years
Learn More – Primary Sources:
JAMA Editorial: Screening for Osteoporosis
FRAX® Fracture Risk Assessment Tool
ACOG Clinical Practice Guideline1: Osteoporosis Prevention, Screening and Diagnosis
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