Updated Osteoporosis Screening Guidelines Released by USPSTF

Nancy A. Melville

June 27, 2018

The US Preventive Services Task Force (USPSTF) published its final recommendations this week on the screening of women for osteoporosis to prevent fractures. The updated guidelines include level B recommendations for the screening of women aged 65 years and older, as well as for younger women who have experienced menopause and also have an increased risk.

"Osteoporosis causes bones to weaken and potentially break, which can lead to chronic pain, disability, loss of independence, and even death," the USPSTF said.

"Clinicians can help women avoid fractures by routinely screening those who are 65 and older, as well as younger, postmenopausal women at higher risk for osteoporosis — such as women who have low body weight, who smoke cigarettes, or whose parent has broken a hip."

The final recommendations, which were published online June 26 in JAMA, apply to older adults without a history of prior fragility fractures or health conditions that could weaken bones.

The USPSTF noted that evidence was insufficient to determine whether men would benefit from osteoporosis screening to prevent fractures.

"While both men and women can develop osteoporosis, there's less evidence to know whether screening and current treatments prevent fractures in men without a history of fractures," USPSTF vice chair Alex H. Krist, MD, MPH, said in a news statement.

"More studies are needed that look at how well treatments work in men who have not had a fracture," he said.

In updating its similar guidelines from 2011, the USPSTF conducted an evidence review of 168 articles on the issue of osteoporosis screening that were determined to be of fair or good quality.

The one randomized clinical trial in the review was the Screening for Prevention of Fractures in Older Women (SCOOP) study of 12,483 women aged 70 to 85 years.

Although that trial did not achieve its primary outcome of screening with the Fracture Risk Assessment Tool (FRAX), resulting in a significant reduction in the incidence of all osteoporotic or clinical fractures, those who received the screening did have significantly fewer hip fractures compared with those who did not receive screening (2.6% vs 3.5%; hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.59 - 0.89).

The analysis further found varying accuracy in bone measurement tests and clinical risk assessments for identifying osteoporosis.

In terms of treatment, whereas bisphosphonates, parathyroid hormone, raloxifene, and denosumab were associated with a lower risk for vertebral fractures in women, evidence on the benefits for men was limited. Statistically significant benefits were seen only in zoledronic acid, showing a reduced risk for vertebral fractures in one randomized clinical trial of 1199 patients.

Whereas the task force's 2011 guidelines on osteoporosis screening endorsed the screening of women younger than 65 years who are considered at risk with FRAX, the new recommendations expand the suggestions to include (in addition to FRAX) the Simple Calculated Osteoporosis Risk Estimation (SCORE); the Osteoporosis Risk Assessment Instrument (ORAI), the Osteoporosis Index of Risk (OSIRIS), and the Osteoporosis Self-Assessment Tool (OST).

Those changes reflect debate, as well as public comment to the draft recommendation, published in November 2017, regarding the accuracy and cutoff levels of any particular tool.

As reported by Medscape Medical News, in discussing the draft recommendation, Krist underscored the need for more data on the use of assessment tools in women younger than 65 years, noting that FRAX was previously indicated as an example, "but we actually don't have good data to say what is the best instrument for assessing risk or what is the exact right threshold," he said.

Two editorials published along with the task force guidelines further reflect the ongoing debate about the osteoporosis screening guidelines.

In one of the editorials, Jane Cauley, DrPH, called the recommendation timely, noting that overall declines in bone mineral density (BMD) screening may indeed have contributed to a plateau seen in what had been a steady decline in age-adjusted incidence of hip fracture.

"[M]ajor deficiencies remain in BMD screening, even among women 65 years and older," she writes.

"Assessment of clinical risk factors is also important, because individuals with the combination of low BMD and an increasing number of risk factors have the highest incidence of hip fracture," adds Cauley, who is from the Department of Epidemiology at the University of Pittsburgh, Pennsylvania.

In a second editorial, Margaret L. Gourlay, MD, MPH, from the Department of Family Medicine at the University of North Carolina, Chapel Hill, argues that whereas the B recommendation may appropriately address evidence on screening for women older than 65 years, the evidence for those younger than 65 years and at risk is less conclusive and should not be given the same level of recommendation.

"Instead of the B recommendation, an I (insufficient evidence) statement from the USPSTF would have been more helpful to motivate further work on the osteoporosis screening protocol for postmenopausal women younger than 65 years," Gourlay asserts. "In its next set of recommendations, the USPSTF should use decision modeling to inform an optimal osteoporosis screening approach. A decision model would ideally test age ranges and intervals for bone-density testing across the entire age spectrum of postmenopausal women, as well as compare risk-assessment tools vs age alone to decide which women younger than 65 years should receive bone-density tests."

Cauley has disclosed no relevant financial relationships. Gourlay reports receiving grant support from the National Institute on Aging for an observational study of osteoporosis screening in men.

JAMA. Published online June 26, 2018. Report full text, Cauley editorial full text,

JAMA Intern Med. Published online June 26, 2018. Gourlay editorial full text

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