What’s New in Screening Guidelines for Osteoporosis?

Question 1. The original 2011 recommendations by the US Preventive Services Task Force (USPSTF) called for osteoporosis screening for which patients?

ANSWER: “In 2011, the US Preventive Services Task Force (USPSTF) recommended screening for osteoporosis in women 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 (B recommendation). The USPSTF concluded that the evidence was insufficient to assess the balance of benefits and harms of screening in men.”¹

Question 2. Of the 16 clinical tools evaluated by the 2018 USPSTF, which was most consistently associated with higher accuracy of prediction of future fracture?

ANSWER: “The evidence for clinical risk assessments varies in the incorporation of BMD and number of risks. In general, tools incorporating BMD had higher accuracy than tools without BMD. The accuracy of tools with more clinical variables was similar to the accuracy of tools with fewer risk factors, suggesting that future research could focus on simpler instruments that can be easily incorporated into clinical practice.”¹

Question 3. What was the impact of intervention vs usual care on 5-year outcomes according to results of the Screening for Osteoporosis in Older Women for the Prevention of Fracture (SCOOP) trial?

ANSWER: “At 5 years’ follow-up, comparing the intervention group with usual care, no difference was reported for the primary outcome of any osteoporotic fracture (12.9% vs 13.6%; hazard ratio [HR], 0.94 [95% CI, 0.85-1.03]), for all clinical fractures (15.3% vs 16.0%; HR, 0.94 [95% CI, 0.86-1.03]), or for mortality (8.8% vs 8.4%; HR, 1.05 [95% CI, 0.93-1.19]). However, a statistically significant difference in hip fracture incidence was observed (2.6% vs 3.5%; HR, 0.72 [95% CI, 0.59-0.89]).”¹

Question 4. True or false? Bone measurement testing to identify osteoporosis is slightly more accurate in men than in women.

ANSWER: “The accuracy of bone measurement tests to identify osteoporosis varied (area under the curve [AUC], 0.32-0.89). The pooled accuracy of clinical risk assessments for identifying osteoporosis ranged from AUC of 0.65 to 0.76 in women and from 0.76 to 0.80 in men; the accuracy for predicting fractures was similar.”¹

Question 5. What are the findings from the 2018 report on the discriminative ability of the Fracture Risk Assessment (FRAX) tool for predicting future fracture?

ANSWER: “The discriminative ability of FRAX for predicting future fracture varied by sex, site of fracture prediction, and whether BMD was used in the risk prediction. For women, pooled estimates based on 10 to 17 studies with 62,054 and 190,795 participants ranged somewhat higher (0.66-0.79). In men, pooled estimates of AUC from 3 to 44 studies (13,970-15,842 participants) ranged from 0.62 to 0.76 (depending on inclusion of BMD in the prediction model). Within that range, pooled estimates were higher for predicting hip fracture than for major osteoporotic fracture and higher when BMD was included in the prediction model. For cohorts of men and women combined, pooled estimates for the prediction of major osteoporotic fracture based on 3 studies (66,777 participants) were similar (AUC without BMD, 0.67 [95% CI, 0.66-0.67; I² = 47.1%]; AUC with BMD, 0.69 [95% CI, 0.69-070; I² = 70.3%]).¹

Question 6. Compared with placebo, what is the effect of treatment with bisphosphonates on the incidence of fractures in women and men?

ANSWER: “Among women, bisphosphonates (as a class) were associated with fewer vertebral fractures compared with placebo (2.1% vs 3.8%). . . . . One RCT in 1199 men reported fewer radiographic vertebral fractures for zoledronic acid compared with placebo (1.5% vs 4.6%; RR, 0.33 [95% CI, 0.16-0.70]). Among women, a pooled analysis of RCTs reporting nonvertebral fractures observed an association with fewer fractures in the treatment group compared with placebo (8.9% vs 10.6%; RR, 0.84 [95% CI, 0.76-0.92]; I² = 0.0%; 8 RCTs [16,438 participants]). The same trial of zoledronic acid in men previously described for vertebral fractures also reported on nonvertebral fractures; no between-group differences in incidence were observed (0.9% vs 1.3%; RR, 0.65 [95% CI, 0.21-1.97]. Among women, the pooled estimate suggested no statistically significant association between treatment with bisphosphonates and incidence of hip fracture (0.70% vs 0.96%; RR, 0.70 [95% CI, 0.44-1.11]; I² = 0.0%; 3 RCTs [n = 8988]. . . . No studies reported on hip fractures in men.”¹

Question 7. Which pharmacotherapies for osteoporosis have been associated with significant adverse events?

ANSWER: Use of bisphosphonates was not associated with serious adverse events or GI events. Although patients treated with denosumab had higher rates of serious infections than placebo groups, confidence intervals for the pooled estimate spanned the null effect. “Women receiving estrogen with or without progesterone experienced a higher rate of gallbladder events, stroke, and venous thromboembolism over 5-year follow-up and an increased risk of urinary incontinence during follow-up of 1 year. In addition, women receiving estrogen plus progestin, compared with women receiving placebo, were found to have a higher risk of invasive breast cancer, coronary heart disease, and probable dementia over 5-year follow-up.”¹