Will the new recommendations affect your approach to osteoporosis screening and treatment? Scroll through our quick slideshow to get all the highlights.
Reference:Â Final Recommendation Statement: Osteoporosis to Prevent Fractures: Screening. U.S. Preventive Services Task Force. July 2018.Â https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/osteoporosis-screening1
The United States Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific clinical preventive services for patients without obvious related signs or symptoms. Recommendations are based on evidence of both benefits and harms of a service and assessment of the balance.
The 2018 recommendations update those last issued in 2011. Osteoporosis screening is recommended for women over the age of 64 and for pre-menopausal women at higher risk for osteoporosis. Thumb through the slides for details on the recommendations and take home points for physicians.
Rationale for New Guidelines. It is estimated that by 2020, 12.3 million people in the US aged >50 years will have osteoporosis and women are at particularly high risk for osteoporotic fractures. However, the USPSTF found convincing evidence that bone measurement tests are accurate for preventing osteoporotic fractures in women and men.
Foundation for Task Force Recommendations. Dual-energy x-ray absorptiometry, or DXA, is the bone measurement modality with the most evidence for predicting fractures. Risk factors for osteoporosis should be determined using tools such as: The Simple Calculated Osteoporosis Risk Estimation (SCORE; Merck), Osteoporosis Risk Assessment Instrument (ORAI), Osteoporosis Index of Risk (OSIRIS), the Osteoporosis Self-Assessment Tool (OST), and the FRAX tool (University of Sheffield).
Osteoporotic Fractures in Men. Hypogonadism, history of cerebrovascular accident, and history of diabetes are associated with an increased risk of fractures, although their clinical use in identifying men who need further bone measurement testing is unclear.
Prevention. The CDC recommends 120-130 minutes/week of moderate-intensity aerobic activity can decrease risk of hip fractures. The National Academy of Medicine recommends daily allowances of calcium and vitamin D based on age. Finally, the USPSTF recommends exercise to prevent falls in community-dwelling adults ≥65 years at increased risk.
Implementation and Accuracy of Screening. Thresholds to identify increased risk of osteoporosis or osteoporotic fractures are ≥6 for SCORE, ≥9 for ORAI, <1 for OSIRIS, and <2 for OST. Screening with peripheral DXA and other imaging techniques may help increase access to screening in geographic locations where machines that perform central DXA may not be available.
Drug Therapy for Osteoporosis. For women, bisphosphonates were found to significantly reduce vertebral fractures (relative risk, 0.57 [95% CI, 0.41-0.78]); and non-vertebral fractures (RR, 0.84 [95% CI, 0.76-0.92]); but not hip fractures (RR, 0.70 [95% CI, 0.44-1.11]). Raloxifene in postmenopausal women reduced vertebral fractures (RR, 0.64 [95% CI, 0.53-0.76]) but not non-vertebral fractures (RR, 0.93 [95% CI, 0.81-1.06]).
Denosumab was found to produce a significant reduction in vertebral fractures (RR, 0.32 [95% CI, 0.26-0.41]), non-vertebral fractures (RR, 0.80 [95% CI, 0.67-0.95]), and hip fractures (RR, 0.60 [95% CI, 0.37-0.97]) in women. Parathyroid hormone in one trial conducted in women found a significant reduction in vertebral fractures (RR, 0.32 [95% CI, 0.14-0.75]) but not non-vertebral fractures (RR, 0.97 [95% CI, 0.71-1.33]).