USPFT Screening Recommendations For Osteoporosis

The following are excerpts from Resource (1), the United States Preventive Services Task Force  screening recomendations for osteoporosis are:

The 10-year risk for osteoporotic fractures can be calculated for individuals by using the FRAX tool and could help to guide screening decisions for women younger than 65 years.

Given the absence of direct evidence that screening for osteoporosis reduces fracture-related morbidity or mortality, studies of long-term health outcomes of screened and nonscreened population groups are important.

Measurement of bone density using DXA has become the gold standard for the diagnosis of osteoporosis and for guiding decisions about which patients to treat.

In a meta-analysis of 7 trials, the relative risk (RR) of vertebral fractures for bisphosphonates compared with placebo was 0.66 (95% CI, 0.50 to 0.89). Two large placebo-controlled trials of raloxifene reported reduced vertebral fractures, with a combined RR for raloxifene of 0.61 compared with placebo (CI, 0.55 to 0.69) 9. A pooled analysis of 9 trials demonstrated a non-statistically significant trend toward a reduction in nonvertebral fractures with bisphosphonates compared with placebo (RR, 0.83 [CI, 0.64 to 1.08]) 3. In the largest trial of bisphosphonates, the Fracture Intervention Trial of alendronate, fractures were significantly reduced only in women with baseline femoral neck T-scores less than −2.5 1.

The harms of drug therapy for osteoporosis have been studied most extensively for bisphosphonates, raloxifene, and estrogen. For bisphosphonates, the evidence demonstrates no definitive increase in the risk for serious gastrointestinal adverse events (for example, perforations, ulcers, bleeding, esophagitis, or esophageal ulceration) in persons who use these medications appropriately. The evidence on the risk for atrial fibrillation with bisphosphonates is conflicting.

Osteonecrosis of the jaw has been associated with bisphosphonates in case reports, but this condition typically develops in patients with cancer who receive higher doses than those normally used for osteoporosis treatment or prevention. Case reports also have described severe musculoskeletal symptoms associated with all of the bisphosphonates 2. In October 2010, the U.S. Food and Drug Administration issued a warning about a possible elevated risk for midfemur fractures in patients using bisphosphonates, especially for patients who have used bisphosphonates for more than 5 years.

Raloxifene and estrogen are associated with higher rates of thromboembolic events compared with placebo. Estrogen increases the risk for stroke, and estrogen with progestin increases the risk for coronary heart disease and breast cancer 2. Limited evidence exists on the harms associated with use of calcitonin and parathyroid hormone for osteoporosis.

The USPSTF found convincing evidence that drug therapies reduce subsequent fracture rates in postmenopausal women. For women aged 65 years or older and younger women who have similar estimates of fracture risk, the benefit of treating screening-detected osteoporosis is at least moderate*. The harms of treatment were found to range from no greater than small* for bisphosphonates and parathyroid hormone to small to moderate for raloxifene and estrogen. Therefore, the USPSTF concludes with moderate certainty that the net benefit of screening for osteoporosis in this group of women is at least moderate*.

*Where are these terms [“small” and “moderate”] defined? I couldn’t find them on the website.

The USPSTF found convincing evidence that drug therapies reduce subsequent fracture rates in postmenopausal women. For women aged 65 years or older and younger women who have similar estimates of fracture risk, the benefit of treating screening-detected osteoporosis is at least moderate. The harms of treatment were found to range from no greater than small for bisphosphonates and parathyroid hormone to small to moderate for raloxifene and estrogen. Therefore, the USPSTF concludes with moderate certainty that the net benefit of screening for osteoporosis in this group of women is at least moderate.

Resources:

(1) Final Recommendation Statement Osteoporosis: Screening from The U.S. Preventive Services Task Force Current as of: January 2011.

(2) NOGG 2017: Clinical guideline for the prevention and treatment of osteoporosis [PDF] from The National Osteoporosis Guideline Group.

(3) FRAX ®Fracture Risk Assessment Tool

(4) AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS — 2016 [PubMed Abstract] [Full Text PDF]. Endocr Pract. 2016 Sep 2;22(Suppl 4):1-42. doi: 10.4158/EP161435.GL.

(5) AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS – 2016–EXECUTIVE SUMMARY [PubMed Abstract]. Endocr Pract. 2016 Sep 2;22(Suppl 4):1-42. doi: 10.4158/EP161435.GL

(6) Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women: A Clinical Practice Guideline Update From the American College of Physicians [Pubmed Abstract] [Full Text HTML] [Link To Download Full Text PDF]. Ann Intern Med. 2017 Jun 6;166(11):818-839. doi: 10.7326/M15-1361. Epub 2017 May 9.

(7) Evidence-based recommendations on the bisphosphonates alendronic acid, ibandronic acid, risedronate sodium and zoledronic acid for treating osteoporosis. Technology appraisal guidance [TA464] Published date: 09 August 2017 Last updated: 07 February 2018:

The purpose of this technology appraisal was to establish at what level of absolute fracture risk bisphosphonates are cost effective. Please note that because of the reduction in prices for oral bisphosphonates over the last few years, the absolute risk level at which these drugs are cost effective is now very low. The absolute risk level at which oral bisphosphonates are recommended as treatment options in this guidance are therefore not clinical intervention thresholds. This technology appraisal guidance should be applied clinically in conjunction with:

  • NICE guideline on assessing the risk of fragility fractures (CG146) that defines who is eligible for osteoporotic fracture risk assessment.
  • NICE quality standard on osteoporosis (QS149) that defines the clinical intervention thresholds for the 10-year fracture probability of a major osteoporotic fracture, in those patients who have undergone fracture risk assessment. These thresholds are based on the NICE-accredited National Osteoporosis Guideline Group guideline.
  • The individual person’s circumstances, goals and informed preferences.

Further information is in the implementation section.

This guidance partially updates NICE technology appraisal guidance on raloxifene for the primary prevention of osteoporotic fragility fractures in postmenopausal women (TA160) and on raloxifene and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women (TA161).

(8) Osteoporosis – Quality standard [QS149] Published date: April 2017 from NICE

NICE has developed guidance and a quality standard on patient experience in adult NHS services (see the NICE pathway on patient experience in adult NHS services), which should be considered alongside these quality statements.

Other quality standards that should be considered when commissioning or providing osteoporosis services include:

A full list of NICE quality standards is available from the quality standards topic library.

(9) Osteoporosis: assessing the risk of fragility fracture Clinical guideline [CG146] Published date: August 2012 Last updated: February 2017  from NICE

(10) UpToDate Pathways Management Of Osteoporosis In Women – podcast posted on June 17, 2017

(11) Osteoporosis Decision Aid from Mayo Clinic Shared Decision Making National Resource Center. You need to register (free) to use the site.

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