Risk Assessment First Urged for Fragility Fracture Screening

Marilynn Larkin

May 11, 2023

A new Canadian guideline on screening for the primary prevention of fragility fractures recommends risk assessment first, before bone mineral density (BMD) testing, for women aged 65 and older. For younger women and men aged 40 and older, screening is not recommended.

To develop the guideline, a writing group from Canadian Task Force on Preventive Health Care commissioned systematic reviews of studies on the benefits and harms of fragility fracture screenings; the predictive accuracy of current risk-assessment tools; patient acceptability; and benefits of treatment. Treatment harms were analyzed via a rapid overview of reviews.

The guideline, published online May 8 in the Canadian Medical Association Journal, is aimed at primary care practitioners for their community-dwelling patients aged 40 and older. The recommendations do not apply to people already taking preventive drugs.

Dr Roland Grad

Nondrug treatments were beyond the scope of the current guideline, but guidelines on the prevention of falls and other strategies are planned, Roland Grad, MD, a guideline author and associate professor at McGill University in Montreal, told Medscape Medical News.

The new guideline says that women aged 65 and older may be able to avoid fracture through screening and preventive medication. An individual's fracture risk can be estimated with a new Fragility Fracture Decision Aid, which uses the Canadian FRAX risk-assessment tool.

"A risk assessment–first approach promotes shared decision-making with the patient, based on best medical evidence," Grad said.

"To help clinicians, we have created an infographic with visuals to communicate the time spent on BMD vs risk assessment first."

New Evidence

"At least three things motivated this new guideline," Grad said. "When we started work on this prior to the pandemic, we saw a need for updated guidance on screening to prevent fragility fractures. We were also aware of new evidence from the publication of screening trials in females older than 65."

To conduct the risk assessment in older women, clinicians are advised to do the following:

  • Use the decision aid (which patients can also use on their own).

  • Use the 10-year absolute risk of major osteoporotic fracture to facilitate shared decision-making about possible benefits and harms of preventive pharmacotherapy.

  • If pharmacotherapy is being considered, request a BMD using DXA of the femoral neck, then reestimate the fracture risk by adding the BMD T-score into the FRAX.

Potential harms associated with various treatments, with varying levels of evidence, include the following: with alendronate and denosumab, nonserious gastrointestinal adverse events; with denosumab, rash, eczema, and infections; with zoledronic acid, nonserious events, such as headache and flulike symptoms; and with alendronate and bisphosphonates, rare but serious harms of atypical femoral fracture and osteonecrosis of the jaw.

"These recommendations emphasize the importance of good clinical practice, where clinicians are alert to changes in physical health and patient well-being," the authors write. "Clinicians should also be aware of the importance of secondary prevention (ie, after fracture) and manage patients accordingly."

"This is an important topic," Grad said. "Fragility fractures are consequential for individuals and for our publicly funded healthcare system. We anticipate questions from clinicians about the time needed to screen with the risk assessment–first strategy. Our modeling work suggests time savings with [this] strategy compared to a strategy of BMD testing first. Following our recommendations may lead to a reduction in BMD testing."

To promote the guideline, the CMAJ has recorded a podcast and will use other strategies to increase awareness, Grad said. "The Canadian Task Force has a communications strategy that includes outreach to primary care, stakeholder webinars, social media, partnerships, and other tactics. The College of Family Physicians of Canada has endorsed the guideline and will help promote to its members."

Other At-Risk Groups?

Aliya Khan, MD, FRCPC, FACP, FACE, a professor in the Divisions of Endocrinology and Metabolism and Geriatrics and director of the fellowship in metabolic bone diseases at McMaster University in Hamilton, Ontario, told Medscape she agrees with the strategy of evaluating women aged 65 and older for fracture risk.

Dr Aliya Khan

"The decision aid is useful, but I would like to see it expanded to other circumstances and situations," she said.

For example, Khan would like to see recommendations for younger women and for men of all ages regarding secondary causes of osteoporosis or medications known to have a detrimental effect on bone health. By not addressing these patients, she said, "we may miss patients who would benefit from a fracture risk assessment and potentially treatment to prevent low-trauma fractures."

A recommendation for younger postmenopausal women was included in the most recent Society of Obstetricians and Gynaecologists Canada guideline, she noted.

Overall, she said, "I believe these recommendations will reduce the excess or inappropriate use of BMD testing and that is welcome."

Funding for the Canadian Task Force on Preventive Health Care is provided by the Public Health Agency of Canada. The task force members report no relevant financial relationships.

CMAJ. Published online May 8, 2023. Full text

Follow Marilynn Larkin on Twitter: @MarilynnL.

For more news, follow Medscape on FacebookTwitterInstagram, and  YouTube.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.