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