Prevention
Task Force Recommends Wider Bone Screening for Older Women
By
Liz Highleyman
Loss
of bone mineral density, ranging from mild osteopenia to more
severe osteoporosis, can lead to debilitating fractures. Osteoporosis
is seen most often among post-menopausal women, but other
factors also increase the risk. According to the Task Force,
by 2012 approximately 12 million Americans older than 50 years
are expected to have osteoporosis, and half of all post-menopausal
women will sustain an osteoporosis-related fracture during
their lifetime
A growing
body of evidence indicates that people with HIV are more
susceptible to bone loss compared with the general population.
Some antiretroviral drugs can cause bone toxicity and chronic
HIV infection has been linked to faster progression of age-related
conditions, but the exact mechanisms are not fully understood.
USPSTF makes recommendations about preventive care for people
without recognized signs or symptoms of a specific condition
-- that is, for the general public -- basing its recommendations
on "a systematic review of the evidence of the benefits
and harms and an assessment of the net benefit of the service."
To support updates to the previous 2002 osteoporosis screening
guidelines, the USPSTF evaluated more recent evidence about
the diagnostic accuracy of osteoporosis and fracture risk
assessment methods, the performance of dual-energy x-ray absorptiometry
(DEXA) and peripheral bone measurement tests, the potential
harms of osteoporosis screening, and the benefits and risks
of bone loss medications.
The updated USPSTF guidelines now recommend:
 |
Osteoporosis
screening for women age 65 years and older. |
|
Screening
for younger women whose fracture risk is equal to or greater
than that of a 65-year-old white woman with no additional
risk factors. |
|
Current
evidence is insufficient to assess the benefits and risks
of bone screening for men; however, the men most likely
to benefit would again be those with a fracture risk equivalent
to that of a 65-year-old white woman. |
The
Task Force noted that "as many as 1 in 2 post-menopausal
women and 1 in 5 older men are at risk for an osteoporosis-related
fracture." In addition to sex and age, known osteoporosis
risk factors include white or Asian race/ethnicity, family
history, low body mass index (BMI), lack of exercise, cigarette
smoking, and heavy alcohol use. Examples of women who have
osteoporosis risk considered equivalent to that of a 65-year-old
white woman include:
|
A
50-year-old current smoker with a BMI of less than 21,
daily alcohol use, and parental fracture history; |
|
A
55-year-old woman with a parental fracture history; |
|
A
60-year-old woman with a BMI of less than 21 and daily
alcohol use; |
|
A
60-year-old current smoker with daily alcohol use. |
Given
its frequency, osteoporosis management remains poorly studied.
"No controlled studies have evaluated the effect of screening
for osteoporosis on fracture rates or fracture-related morbidity
or mortality," the Task Force authors wrote.
With regard to screening and management, USPSTF concluded:
|
For
women aged 65 or older and younger women with equivalent
fracture risk, there is "moderate certainty"
that the net benefit of DEXA screening for osteoporosis
is "at least moderate." |
|
For
men, evidence of the benefits of osteoporosis screening
is lacking and "the balance of benefits and harms
cannot be determined." |
|
However,
potential harms of screening for men are "likely
to be small" and consist primarily of opportunity
costs (i.e., other ways resources could be used). |
|
There
is "convincing evidence" that bone measurement
tests predict short-term risk for osteoporosis-related
fractures in women and men. |
|
Evidence
is lacking about optimal intervals for repeated bone screening. |
|
No
new studies were identified that described harms of osteoporosis
screening for women or men. |
|
The
FRAX algorithm -- which incorporates factors such as age,
BMI, family history, and tobacco and alcohol use -- is
recommended for assessing fracture risk. |
|
For
post-menopausal women with no previous osteoporosis-related
fractures, there is "convincing evidence that drug
therapies reduce fracture risk." |
|
For
women aged 65 or older and younger women with equivalent
risk, "the benefit of treating screening-detected
osteoporosis is at least moderate." |
|
There
is "inadequate evidence" that drug therapies
reduce the risk of fractures in men, and the lack of randomized
trials of osteoporosis in men is "a critical gap
in the evidence." |
|
There is "adequate evidence" that the harms
of bisphosphonates, the most commonly prescribed drugs
to prevent bone loss, are "no greater than small." |
The
USPSTF recommendations do not specifically address people
with HIV, but most experts include HIV positive women and
men among those who are at increased risk for bone loss and
could benefit from earlier or more frequent osteoporosis screening.
Based on a review of evidence, Grace McComsey and an international
team of colleagues published guidelines in the October
15, 2010 issue of Clinical Infectious Diseases
recommending that all HIV positive women who have reached
menopause and HIV positive men age 50 or older, as well as
those with a history of past fragility fractures, should undergo
DEXA bone density screening every 2 to 5 years. To prevent
bone problems, the authors added, people with HIV should take
calcium and vitamin D supplements, get adequate sun exposure,
and exercise regularly.
USPSTF indicated that it has also reviewed evidence on prevention
of falls among older adults and is looking at the preventive
value of vitamin D and calcium supplements for osteoporosis-related
fractures. When completed, these recommendations will be available
at www.uspreventiveservicestaskforce.org.
1/21/11
Reference
U.S.
Preventive Services Task Force. Screening for Osteoporosis:
U.S. Preventive Services Task Force Recommendation Statement.
Annals of Internal Medicine (Free
full text). January 17, 2011 (Epub ahead of print).
Other Source
T Neale. Osteoporosis Recs Urge Screening for More Women.
MedPage Today. January 18, 2011.
