screening for osteoporosis

Introduction

Use FRAX fracture risk assessment tool.

Indications

• all women >= 65 years of age*
• women < 65 years with 10 year fracture risk (FRAX)* > 9.3%
• DXA screening for osteoporosis in older women regardless of age if life expectancy is >= 2-5 years#
• men > 50 years old with risk factor
  • glucocorticoids, androgen antagonists, HIV1 infection
    • HAART containing tenofovir disoproxil fumarate associated with greater decline in bone mineral density than other regimens
  • USPSTF concludes that evidence is insufficient to recommend screening for men

* 10 year risk of fracture (FRAX) for 65 year old white woman without any additional risk fractures is 9.3%

# treatment of osteoporosis with a bisphosphonate has an expected time-to-benefit of 1-2 years

screening higher-risk women >= 65 years is associated with a small absolute risk reduction in hip fracture & other major fractures

• risk assessment tools, bone mineral density alone, or both have poor to modest discrimination for predicting fracture

Contraindications

• do not screen premenopausal women

Laboratory

• 25-hydroxyvitamin D in serum
  • National Academy of Medicine notes a lack of evidence as to benefits or effectiveness of screening for deficiency of vitamin D (SOE=D)

Radiology

• bone mineral density of lumbar spine & femoral neck
• USPSTF recommendations for bone-mineral density testing for
  • screening all women beginning at age 65 & women < 65 if their 10-year fracture risk >= that of a woman> 65 without additional risk factors ~ 9% (use WHO's FRAX tool to estimate fracture risk)
    • USPSTF does not propose interval screening guidelines
    • despite this, & evidence presented below, GRS11 implies 5 year screening interval for 70 yo woman with T-scores >= -1.0
      • it seems GRS11 is in error according to an accompanying explanation
  • premature menopause without estrogen replacement implies high-risk (does not appear to be in FRAX tool)
• Medicare coverage of bone mineral density for men is dependent on the presence of specific risk factors (glucocorticoid use)
• for women with normal bone mineral density or mild osteopenia (T score > -1.50)
  • >= 10 years between screenings
  • 15 year interval between screenings
• 5 year interval screening for women with moderate osteopenia (-1.50 > T score > -2.50)
• bone-mineral density T score <= -2.50 = osteoporosis

Management

• recommendations apply to all racial and ethnic groups
• not enough evidence to determine whether routine screening is beneficial or harmful for men
• USPSTF does recommend screening men without risk factors for osteoporoisis
• National Osteoporosis Foundation does recommend screening for all men >= 70 years of age
• women at low risk for osteoporosis may be able to forgo bone mineral density screening
• Osteoporosis Self-Assessment Tool as effective as the FRAX (without bone mineral density) in identifying women at very low risk for osteoporosis

More general terms

• screening

Additional terms

• bone mineral density (BMD)
• FRAX fracture risk assessment tool
• osteoporosis