Osteoporosis screening

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

The risk of fracture due to osteoporosis is threatening, affecting one out of two postmenopausal women and one out of five men older than 50 years. The 10-year risk for any osteoporosis-related fractures in a 65-year-old white woman with no other risk factor is 9.3%. According to the guidelines of USPSTF, all women ≥ 65 years old along with women < 65 years old with a high risk of fracture are the target of screening for osteoporosis, but there is not any recommendation to screen men for the disease. Dual energy x-ray absorptiometry (DXA) of both hip and lumbar spine bones and quantitative ultrasonography of the calcaneus are two major methods suggested for screening osteoporosis.

Screening

Risk assessment

The risk of fracture due to osteoporosis is threatening, affecting one out of two postmenopausal women and one out of five men older than 50 years. Osteoporosis usually affects the Caucasian population. The rate of osteoporosis is higher in the elderly. The 10-year risk for any osteoporosis-related fractures in a 65-year-old white woman with no other risk factor is 9.3%. The 10-year probability of hip fracture can be estimated by the FRAX tool based on the presence or absence of clinical risk factors in addition to the bone mineral density (BMD) at the femoral neck.

Screening criteria

The US Preventive Services Task Force (USPSTF) divides the population into three groups, categorizing them on the basis of their need to be screened for osteoporosis. They include:

• Women of age ≥ 65 year, without any fracture history or pathological reason for osteoporosis
• Women of age <65 years, with 10-year fracture risk of not less than a 65-year-old white woman (who has not any other risk factor)
• Men with no history of osteoporosis

According to the guidelines of USPSTF, the first two groups (women) are the target of screening for osteoporosis. There is no recommendation to screen the third group (men) for the disease.

The USPSTF recommendations from 2018 included:

• "The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older. (B recommendation)"
• "The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in postmenopausal women younger than 65 years at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool. (B recommendation) ""
• "The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis to prevent osteoporotic fractures in men. (I statement)."

Clinical prediction rules are available to guide the selection of women for screening.

• [ORAI https://www.physio-pedia.com/The_Osteoporosis_Risk_Assessment_Instrument_(ORAI)]
• FRAX has the best area under the ROC curve according the
• A previous study found that the Osteoporosis Risk Assessment Instrument (ORAI) is the most sensitive strategy.

Screening men

Regarding the screening process for men, a cost-analysis study suggests that screening may be "cost-effective for men with a self-reported prior fracture beginning at age 65 years, and for men 80 years and older with no prior fracture".

The American College of Physicians recommended:

• "clinicians obtain dual-energy x-ray absorptiometry for men who are at increased risk for osteoporosis and are candidates for drug therapy"
  • "High-quality evidence shows that age, low body weight, physical inactivity, and weight loss are strong predictors of an increased risk for osteoporosis in men."
  • "There is also moderate-quality evidence that previous fragility fracture, systemic corticosteroid therapy, androgen deprivation therapy, and spinal cord injury are predictors of an increased risk for osteoporosis in men. Cigarette smoking and low dietary intake of calcium predict low bone mass."

Glucocorticoid therapy =

UpToDate recommends recommends treatment if "prednisone >30 mg/day for >1 month".

Screening tool

There are two major methods, that are suggested to be used for screening for osteoporosis:

• Dual energy x-ray absorptiometry (DXA) of both hip and lumbar spine bones
• Quantitative ultrasonography of the calcaneus

Advantages of ultrasonography over DXA scan:

Although quantitative ultrasonography has numerous advantages when compared to DXA but still current diagnostic and treatment criteria rely on DXA of the hip and lumbar spine. The advantages include:

• Lower cost
• More portable
• Lower ionizing radiation exposure

Screening protocol

After an initial screening is done for bone mineral density (BMD), optimal intervals to repeat the tests include:

• 15 years for women with normal bone density or mild osteopenia: T-score of greater than −1.50
• 5 years for women with moderate osteopenia: T-score of −1.50 to −1.99
• 1 year for women with advanced osteopenia: T-score of −2.00 to −2.49

Osteoporosis Screening Recommendations by other Organizations

Organizations	Women	Men
National Osteoporosis Foundation (NOF)	BMD testing for: All ≥ 65 years old Postmenopausal <65 years old, based on risk factor profile	BMD testing for: All men ≥70 years old Men aged 50-69 years old, based on fracture risk profile*
World Health Organization (WHO)	Indirect records suggest screening women ≥65 years old, while no direct record suggests using BMD testing for holistic screening programs	-
American College of Physicians	-	Clinicians should investigate older men for osteoporosis risk factors DXA is used to screen men with increased risk Men with increased risk may be the candidates for drug therapy for osteoporosis
American Congress of Obstetricians and Gynecologists (ACOG)	BMD testing for: Age ≥65 years Postmenopausal <65 years old, with 1 or more risk factors	-

§ Fracture risk profiles are mentioned in the table below.

	Adults ≥ 40 years of age	Adults <40 years of age
High fracture risk	Prior osteoporotic fracture(s) Hip or spine bone mineral density T score ≤ -2.5, in men age ≥50 years and postmenopausal women FRAX 10-year risk of major osteoporotic fracture ≥ 20% FRAX 10-year risk of hip fracture ≥ 3%	Prior osteoporotic fracture(s)
Moderate fracture risk	FRAX 10-year risk of major osteoporotic fracture 10–19% FRAX 10-year risk of hip fracture >1% and <3%	Hip or spine bone mineral density Z score <-3 or Rapid bone loss (≥10% at the hip or spine over 1 year) and Continuing glucocorticoid treatment at ≥7.5 mg/day for ≥6 months
Low fracture risk	FRAX 10-year risk of major osteoporotic fracture <10% FRAX 10-year risk of hip fracture ≤1%	None of above risk factors other than glucocorticoid treatment

References

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