Prevention Task Force Recommends Wider Bone Screening for Older Women

The U.S. Preventive Services Task Force (USPSTF) this week issued revised guidelines, published in the January 17, 2011, advance online edition of Annals of Internal Medicine, recommending that all women age 65 and older should be screened for bone loss, along with younger women -- and presumably men -- who have equivalent risk. HIV and its treatment may raise the likelihood of bone loss, and experts recently recommended earlier bone screening for HIV positive women and men.

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.