Heidi D. Nelson, MD, MPH; Elizabeth M. Haney, MD; Tracy Dana, MLS; Christina Bougatsos, BS; Roger Chou, MD
This review updates evidence since the 2002 U.S. Preventive Services Task Force recommendation on osteoporosis screening.
To determine the effectiveness and harms of osteoporosis screening in reducing fractures for men and postmenopausal women without known previous fractures; the performance of risk-assessment instruments and bone measurement tests in identifying persons with osteoporosis; optimal screening intervals; and the efficacy and harms of medications to reduce primary fractures.
Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through the fourth quarter of 2009), MEDLINE (January 2001 to December 2009), reference lists, and Web of Science.
Randomized, controlled trials of screening or medications with fracture outcomes published in English; performance studies of validated risk-assessment instruments; and systematic reviews and population-based studies of bone measurement tests or medication harms.
Data on patient populations, study design, analysis, follow-up, and results were abstracted, and study quality was rated by using established criteria.
Risk-assessment instruments are modest predictors of low bone density (area under the curve, 0.13 to 0.87; 14 instruments) and fractures (area under the curve, 0.48 to 0.89; 11 instruments); simple and complex instruments perform similarly. Dual-energy x-ray absorptiometry predicts fractures similarly for men and women; calcaneal quantitative ultrasonography also predicts fractures, but correlation with dual-energy x-ray absorptiometry is low. For postmenopausal women, bisphosphonates, parathyroid hormone, raloxifene, and estrogen reduce primary vertebral fractures. Trials are lacking for men. Bisphosphonates are not consistently associated with serious adverse events; raloxifene and estrogen increase thromboembolic events; and estrogen causes additional adverse events.
Trials of screening with fracture outcomes, screening intervals, and medications to reduce primary fractures, particularly those enrolling men, are lacking.
Although methods to identify risk for osteoporotic fractures are available and medications to reduce fractures are effective, no trials directly evaluate screening effectiveness, harms, and intervals.
Agency for Healthcare Research and Quality.
In 2002, the U.S. Preventive Services Task Force recommended bone density testing for women 65 years or older and women 60 to 64 years with increased fracture risk and made no recommendation for or against screening other women or men.
This review of studies related to osteoporosis screening that were published from January 2001 to December 2009 found no trials of screening. Evidence showed that risk-assessment instruments predict low bone density and fractures, dual-energy x-ray absorptiometry predicts fractures similarly in both sexes, and calcaneal ultrasonography predicts fracture but correlates poorly with dual-energy x-ray absorptiometry. Trials show that bisphosphonates, parathyroid hormone, raloxifene, and estrogen prevent primary vertebral fractures in women. Prevention trials are lacking in men.
Recommendations for osteoporosis screening must be based on indirect evidence that is largely from studies of women.
KQ = key question.
KQ = key question; USPSTF = U.S. Preventive Services Task Force.
* Cochrane databases include the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews.
† Identified from reference lists and suggested by experts.
‡ Some abstracts and articles were considered for more than 1 KQ.
§ Additional articles are described in the technical report (19).
Appendix Table 1.
Appendix Table 2.
Appendix Table 3.
Appendix Table 4.
Appendix Table 5.
Estimates are based on age-specific prevalence rates of osteoporosis (139) and effects on fracture reduction with bisphosphonates from the Fracture Intervention Trial (82).
Major osteoporotic fractures include hip, clinical vertebral, proximal humerus, and distal forearm. Highlighted risks equal or exceed the reference case (woman aged 65 years with no risk factors: 9.3% for osteoporotic fracture; 1.2% for hip fracture). BMI = body mass index.
* Normal BMI = 25.0 kg/m2 based on average height of 163 cm (64.17 in) and weight of 66.5 kg (146.61 lb). Low BMI = 21.2 kg/m2 based on average height of 163 cm (64.17 in) and weight of 56.7 kg (125 lb).
† Daily alcohol use of 3 or more units/d (approximately 3 oz each).
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Nelson HD, Haney EM, Dana T, Bougatsos C, Chou R. Screening for Osteoporosis: An Update for the U.S. Preventive Services Task Force. Ann Intern Med. ;153:99–111. doi: 10.7326/0003-4819-153-2-201007200-00262
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Published: Ann Intern Med. 2010;153(2):99-111.
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