USPSTF Screening Guidelines
| The USPSTF recommends screening for osteoporosis in women aged 65 years and older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. |
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men.
The USPSTF recommends using dual-energy x-ray absorptiometry to screen all women 65 years and older, and younger women who have an increased fracture risk as determined by the World Health Organization’s FRAX Fracture Risk Assessment Tool.
How to calculate the fracture risk of younger women
The USPSTF recommends screening for osteoporosis with DXA scan in women aged 65 or older and also younger women whose fracture risk is equal to or greater than that of a 65-year old white woman. The question is, how do you determine the fracture risk of younger women aged 50-64?
To determine risk in women age 50–64, the USPSTF recommends using a 10-year fracture risk threshold of 9.3% calculated using the U.S. FRAX tool (www.shef.ac.uk/FRAX).
Why 9.3%? Because based on the U.S. FRAX tool, a 65-year-old white woman with no other risk factors has a 9.3% 10-year risk for any osteoporotic fracture. If you fill out the FRAX tool for a 65-year-old white woman in the U.S and put the BMI to be 25, you will get 9.3 % as the calculated risk for a major osteoporotic fracture. It also shows the risk of 1.2 for a hip fracture. But the risk that you need to use is the 9.3% risk of a major osteoporotic fracture.
That means 9.3% is the 10-year risk for any osteoporotic fracture in a 65-year-old white woman. Therefore, any woman with a major fracture risk of 9.3% or greater on the FRAX score needs a DEXA scan to screen for osteoporosis.
ACP, National Osteoporosis Foundation, Endocrine Society
These recommend BMD assessment with DXA scan in men > 70 years of age.
Dr. Gemma Kim said she also screens people 15 years from the year they started menopause. For example, if someone had the ovaries taken out and went on menopause at 35, then she would screen them at 50, not 35.
Screening Tests
“The most commonly used bone measurement tests used to screen for osteoporosis are DXA of the hip and lumbar spine and quantitative ultrasonography of the calcaneus. Quantitative ultrasonography is less expensive and more portable than DXA and does not expose patients to ionizing radiation. Quantitative ultrasonography of the calcaneus predicts fractures of the femoral neck, hip, and spine as effectively as DXA. However, current diagnostic and treatment criteria for osteoporosis rely on DXA measurements only, and criteria based on quantitative ultrasonography or a combination of quantitative ultrasonography and DXA have not been defined.” USPSTF
Screening Intervals
“The potential value of rescreening women whose initial screening test did not detect osteoporosis is to improve fracture risk prediction. A lack of evidence exists about optimal intervals for repeated screening and whether repeated screening is necessary in a woman with normal BMD. Because of limitations in the precision of testing, a minimum of 2 years may be needed to reliably measure a change in BMD; however, longer intervals may be necessary to improve fracture risk prediction. A prospective study of 4,124 women aged 65 years or older found that neither repeated BMD measurement nor the change in BMD after 8 years was more predictive of subsequent fracture risk than the original measurement.” USPSTF
Treatment
“In addition to adequate calcium and vitamin D intake and weight-bearing exercise, multiple drug therapies are approved by the U.S. Food and Drug Administration to reduce fractures, including bisphosphonates, parathyroid hormone, raloxifene, and estrogen. The choice of therapy should be an individual one based on the patient’s clinical situation and the tradeoff between benefits and harms. Clinicians should provide patient education on how to use drug therapies to minimize adverse effects. For example, esophageal irritation from bisphosphonate therapy can be reduced by taking the medication with a full glass of water and by not lying down for at least 30 minutes afterward.” USPSTF
Reference
USPSTF
NOF
(http://www.aafp.org/afp/2015/0815/p261.html)