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Evidence Summary

Other Supporting Document for Osteoporosis: Screening

Preface

By Heidi D. Nelson, MD, MPH; Elizabeth M. Haney, MD; Tracy Dana, MLS; Christina Bougatsos, BS; and Roger Chou, MD

Address correspondence to: Heidi D. Nelson, MD, MPH, Oregon Evidence-based Practice Center, Oregon Health & Science University, Mailcode BICC, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239-3098.


The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.

This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

This article was first published in Annals of Internal Medicine on July 6, 2010 (Annals of Internal Medicine 2010;153(2):1-14; www.annals.org). Select for copyright and source information.

Editor's Note: As part of the U.S. Preventive Services Task Force's (USPSTF) ongoing commitment to clarity about its work and methods, it has begun to invite public comment on all draft recommendation statements before publication of the final statements. Because of this new initiative, the recommendation on screening for osteoporosis does not appear with this accompanying background review. When the USPSTF's draft recommendation statement on screening for osteoporosis was published on July 6, 2010, the public was offered the opportunity to comment on the draft recommendation statement. The comment period for this recommendation is now closed. The USPSTF will consider submitted comments when it finalizes the recommendation for subsequent publication in Annals and posting on the USPSTF Web site at http://www.uspreventiveservicestaskforce.org/.

Abstract

Background: This review updates evidence since the 2002 U.S. Preventive Services Task Force recommendation on osteoporosis screening.

Purpose: To determine the effectiveness and harms of osteoporosis screening in reducing fractures for men and postmenopausal women without known previous fractures; the performance of risk-assessment instruments and bone measurement tests in identifying persons with osteoporosis; optimal screening intervals; and the efficacy and harms of medications to reduce primary fractures.

Data Sources: Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through the fourth quarter of 2009), MEDLINE® (January 2001 to December 2009), reference lists, and Web of Science.

Study Selection: Randomized, controlled trials of screening or medications with fracture outcomes published in English; performance studies of validated risk-assessment instruments; and systematic reviews and population-based studies of bone measurement tests or medication harms.

Data Extraction: Data on patient populations, study design, analysis, follow-up, and results were abstracted, and study quality was rated by using established criteria.

Data Synthesis: Risk-assessment instruments are modest predictors of low bone density (area under the curve, 0.13 to 0.87; 14 instruments) and fractures (area under the curve, 0.48 to 0.89; 11 instruments); simple and complex instruments perform similarly. Dual-energy x-ray absorptiometry predicts fractures similarly for men and women; calcaneal quantitative ultrasonography also predicts fractures, but correlation with dual-energy x-ray absorptiometry is low. For postmenopausal women, bisphosphonates, parathyroid hormone, raloxifene, and estrogen reduce primary vertebral fractures. Trials are lacking for men. Bisphosphonates are not consistently associated with serious adverse events; raloxifene and estrogen increase thromboembolic events; and estrogen causes additional adverse events.

Limitation: Trials of screening with fracture outcomes, screening intervals, and medications to reduce primary fractures, particularly those enrolling men, are lacking.

Conclusion: Although methods to identify risk for osteoporotic fractures are available and medications to reduce fractures are effective, no trials directly evaluate screening effectiveness, harms, and intervals.

Primary Funding Source: Agency for Healthcare Research and Quality.

Introduction

This systematic evidence review is an update for the U.S. Preventive Services Task Force (USPSTF) recommendation on screening for osteoporosis. In 2002, on the basis of results of a previous review1, 2, the USPSTF recommended bone density screening for women 65 years or older and for women aged 60 to 64 years at increased risk for osteoporotic fractures3, 4. They made no recommendations for or against screening postmenopausal women younger than 60 years or women aged 60 to 64 years without increased risk. Men were not considered in the previous recommendation.

Osteoporosis is a systemic skeletal condition characterized by low bone mass and microarchitectural deterioration of bone tissue that increases bone fragility and risk for fractures5. Osteoporosis may occur without a known cause or secondary to another condition. Osteoporosis is diagnosed in persons on the basis of presence of a fragility fracture or by bone mass measurement criteria. These criteria were developed by the World Health Organization from epidemiologic data that describe the normal distribution of bone mineral density (BMD) in a young healthy reference population 6. Osteoporosis is diagnosed when the BMD at the spine, hip, or wrist is 2.5 or more SDs below the reference mean (T-score of -2.5 or less), and low bone density or mass is diagnosed when BMD is from 1.0 to 2.5 SDs below the reference mean. Other important components of the condition, such as rate of bone loss and quality of bone, are not well characterized clinically.

Estimates indicate that as many as 50% of Americans older than 50 years will be at risk for osteoporotic fractures during their lifetimes5. This translates to 12 million persons with osteoporosis by 20125. Specific prevalence rates depend on how bone density is measured and characteristics of the population. Rates for women are higher than those for men; rates vary by race, with the highest rates in white persons; and rates for all demographic groups increase with age7-9. Older persons have much higher fracture rates than younger persons with the same bone density because of increasing risks from other factors, such as bone quality and tendency to fall10.

All types of fractures are associated with higher mortality rates11-14. Men are more likely than women to die in the year after a hip fracture, with mortality rates for men estimated at up to 37.5%15. Fractures adversely affect function and quality of life, resulting in chronic pain, disability, and high costs5. Despite increased awareness of the magnitude and consequences of osteoporosis and recommendations for screening and treatment from several groups, osteoporosis is underdetected and inadequately treated in the United States16, 17. Reasons for this are unclear, although the differing recommendations for identifying candidates for testing and treatment, confusion in interpreting results of testing, and fragmentation of health care may contribute18.

This update focuses on new studies and evidence gaps that were unresolved at the time of the 2002 USPSTF recommendation. These include the effectiveness and harms of osteoporosis screening in reducing fractures for men as well as postmenopausal women without known previous fractures; the performance of risk-assessment instruments and bone measurement tests in identifying persons with osteoporosis; optimal screening intervals; and efficacy and harms of medications to reduce primary fractures in a screening-detected population.

 

Methods

The USPSTF and the Agency for Healthcare Research and Quality (AHRQ) developed key questions for this review. Investigators created an analytic framework, incorporating the key questions and outlining the patient populations, interventions, outcomes, and harms of the screening process (Appendix Figure 1). The target populations include postmenopausal women and men older than 50 years without known previous osteoporosis-related fragility fractures or secondary causes of osteoporosis. Harms of screening include consequences of false-positive and false-negative tests, patient anxiety and other psychosocial responses, unnecessary treatment, as well as adverse outcomes from medications.

Data Sources and Searches

We searched the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through the fourth quarter of 2009) and MEDLINE® (January 2001 to December 2009) for relevant studies and systematic reviews. A technical report19 describes search strategies and additional details. We also conducted secondary referencing by manually reviewing reference lists of key papers and searching citations by using Web of Science20 (Appendix Figure 2).

Study Selection

We selected studies on the basis of inclusion and exclusion criteria developed for each key question19. We included randomized, controlled trials (RCTs) with fracture or fracture-related morbidity and mortality outcomes to determine the effectiveness of osteoporosis screening and studies of any design to determine harms from screening.

To determine the accuracy and clinical applicability of risk-assessment instruments, we included studies of externally validated instruments that reported performance characteristics. Instruments were included if they were derived from an initial population and then tested in a separate population; derived from computer modeling, consensus, or another study and then tested in a novel population; or derived from any source and tested against T-scores or actual fracture rates in a population. We did not include internally validated measures (imputation methods or cross-validation). To determine the performance of bone measurement tests in predicting fractures, we limited studies to existing systematic reviews and technology assessments of procedures currently used in U.S. practice and large population-based studies relevant to primary care settings. We included any studies providing data about screening intervals.

To evaluate the efficacy and harms of medications to reduce fractures in a screening-detected population, we included RCTs and meta-analyses of RCTs that reported fracture and fracture-related outcomes and adverse effects for medications used in the United States. Outcomes included specific types of fractures; fracture-related morbidity, including loss of function, pain, quality of life, and other reported health outcomes; and fracture-related mortality. We excluded nondrug therapies because they are addressed in other reviews for the USPSTF (for example, calcium, vitamin D, exercise, and fall prevention) and combination therapies. We focused on trials that enrolled patients without known previous osteoporosis-related fragility fractures, such as vertebral compression or hip fractures, and without known secondary causes of osteoporosis because this population is most relevant to screening. We included trials that met 1 of the following 3 criteria. First, the trial excluded persons with previous vertebral or other presumably osteoporotic fractures. Second, the trial permitted persons with previous osteoporotic fractures, but the overall proportion of participants with fractures was less than 20%, or the trial reported results separately for participants with and without previous fractures. We considered trials meeting this criterion to be applicable to primary prevention based on epidemiologic data21. Third, the trial did not report the proportion of participants with previous osteoporotic fractures, but inclusion criteria did not select persons on the basis of presence of a previous fracture, and mean BMD T-scores were -3.0 or more. This threshold was selected because placebo-controlled trials that enrolled more than 20% of women with previous fractures reported mean baseline BMD T-scores less than -3.022-25.

We determined harms from good- and fair-quality systematic reviews that pooled primary and secondary prevention trials after verifying data abstraction and statistical analyses and large controlled observational studies. For osteonecrosis of the jaw, we included systematic reviews summarizing evidence from case reports and series.

Data Abstraction and Quality Assessment

Details about the patient population, study design, analysis, follow-up, and results were abstracted. By using predefined criteria developed by the USPSTF26, 2 investigators rated the quality of studies (good, fair, or poor) and resolved discrepancies by consensus. We assessed the overall strength of the body of evidence for each key question (good, fair, or poor) by using methods developed by the USPSTF on the basis of the number, quality, and size of studies; consistency of results between studies; and directness of evidence26.

Data Synthesis and Analysis

We pooled results of primary prevention trials of bisphosphonates for various fracture outcomes (vertebral, nonvertebral, hip, wrist, and ankle) by using the random-effects Mantel-Haenszel method in Review Manager (RevMan), Version 5.0 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark). We chose the random-effects model because of differences in study participant characteristics, such as baseline BMD, previous fractures, and risk factors for osteoporosis. Results were also stratified by type of bisphosphonate if sufficient data for pooling were available. For trials that evaluated several doses, we focused on outcomes for doses similar to those currently recommended in the package inserts approved by the U.S. Food and Drug Administration (FDA).

Several trials included in the meta-analyses reported few, rare, or 0 fracture events. The primary analyses excluded trials with 0 events in both groups, resulting in loss of data, and applied a constant continuity correction of 0.5 for trials with 0 events in 1 group, potentially biasing inferences27, 28. In addition, the random-effects Mantel-Haenszel method we used may be unsuitable when events are rare27. We therefore conducted sensitivity analyses to determine the effects of alternate pooling methods on estimates by using the Peto odds ratio (OR), fixed-effects Mantel-Haenszel method with an alternative continuity correction, and the pooled arcsine difference27-29. The Appendix provides details about the methods and results of these analyses, as well as other sensitivity analyses.

Role of the Funding Source

The AHRQ funded this work, developed key questions in conjunction with USPSTF members, and assisted with internal and external review of the draft, but had no additional role in the design, conduct, or reporting of the review. External experts not affiliated with the USPSTF reviewed the draft manuscript.

Results

Effectiveness and Harms of Osteoporosis Screening in Reducing Fractures, Morbidity, and Mortality (Key Questions 1 and 4)

We identified no trials of the effectiveness of screening and no studies evaluating potential harms from screening. Adverse outcomes from medications are addressed by key question 6.

Performance of Risk-Assessment Instruments to Stratify Individuals Into Risk Categories (Key Question 2)

Thirty-three studies evaluated 21 externally validated clinical risk-assessment instruments and reported performance estimates of the area under the curve (AUC) for the receiver-operating characteristic curve predicting either bone density or fractures30-62. Eight instruments were tested with men30, 36, 45-47, 57, 60, 61. Instruments include from 133, 34, 37, 38, 48 to more than 1532, 45 variables, although most include age, weight or body mass index, and previous fracture. Family history of fractures, smoking status, and estrogen use are also commonly included. Important methodological limitations of studies include nonrepresentative samples, cross-sectional rather than prospective data collection, inconsistent performance of the reference standard, and differences in performance measures across studies. The technical report19 describes additional studies of instruments that were internally validated or not validated or did not report AUC estimates, along with studies that combined clinical risk factors with peripheral dual-energy x-ray absorptiometry (DEXA) or quantitative ultrasonography (QUS) measures.

Twenty-three studies of 14 instruments to predict low BMD (T-score of -2.5 or less) reported AUC estimates ranging from 0.13 to 0.87, with most between 0.60 and 0.830, 32-35, 37, 38, 42-44, 47-53, 55, 56, 58-61 (Table 1). Although some instruments had high AUC estimates in selected studies, none demonstrated high estimates in several studies. Instruments with fewer risk factors often did as well or better than those with more. For example, the Osteoporosis Self-assessment Screening Tool (OST) includes only age and weight, has similar AUC estimates as other more complicated instruments, and has been validated in both men30, 47, 61 and women37, 43, 44, 48, 53, 55. Eleven studies of 11 instruments to predict fractures reported AUC estimates from 0.48 to 0.8931, 36, 39-41, 45, 46, 52, 54, 57, 62 (Table 1). Four studies included both men and women36, 45, 46, 57; all others included only women.

The World Health Organization and National Osteoporosis Foundation recently developed the FRAX instrument to predict individual fracture risks46, 63. FRAX estimates adjust for nationality and include femoral neck BMD if available and age, sex, height, body mass index, previous fracture, family history of fracture, glucocorticoid use, current smoking status, daily alcohol use of 3 units or more, rheumatoid arthritis, and other secondary causes of osteoporosis. FRAX was derived from combined data from 46,340 persons from 9 different cohorts and subsequently tested in 230,486 persons from 11 validation cohorts46. Seven derivation cohorts and 1 validation cohort included men. Although the risk calculator is available on a Web site (www.shef.ac.uk/FRAX/), the source code is not accessible. The AUC estimates for FRAX ranged from 0.54 to 0.78 for osteoporotic fractures40, 46, 57 and 0.65 to 0.81 for hip fractures46 (Table 1). Three studies compared FRAX with simple models, such as age and BMD or age and fracture history, and found that simple models did as well as FRAX in predicting hip and other clinical fractures40, 64 and vertebral fractures39. We did not identify studies that prospectively tested FRAX in clinic populations or determined its effectiveness in selecting patients for therapy.

Performance of DEXA in Predicting Fractures in Men (Key Question 3a)

Two good-quality, prospective cohort studies evaluated the performance of DEXA in predicting fractures in men and compared results of men with those of women65-67. The Rotterdam Study compared 4,731 women and 3,075 men 55 years or older from the same community at the same time65, 66. Nonvertebral fractures were determined 6 to 7 years after baseline BMD from fracture reports, and vertebral fractures were determined from follow-up radiography by using morphometric criteria. For each sex-specific SD decrease in femoral neck BMD, the hazard ratio for all nonvertebral fractures was 1.4 (95% CI, 1.2 to 1.6) for men and 1.5 (CI, 1.4 to 1.6) for women and were similar for several site-specific fractures65, 66. The hazard ratio for vertebral fractures was 1.8 (CI, 1.3 to 2.4) for men and 1.9 (CI, 1.6 to 2.4) for women.

A study of BMD and risk for hip and nonvertebral fractures compared men enrolled in MrOS (Osteoporotic Fractures in Men Study) with women in SOF (Study of Osteoporotic Fractures) and reported similar results67. However, in this study, DEXA of the femoral neck was associated with a higher relative risk for hip fracture in men (3.68 [CI, 2.68 to 5.05]) than in women (2.48 [CI, 2.09 to 2.95]). Additional studies are consistent with findings from the Rotterdam Study and MrOS68-70. Variations in estimates may be due to the different patient populations, study designs, and other factors.

Performance of Peripheral Bone Measurement Tests in Predicting Fractures (Key Question 3b)

Several peripheral bone measurement tests have been developed, although clinical practice and recent research focus on QUS of the calcaneous. For postmenopausal women, 7 studies of DEXA and QUS report similar AUC estimates and risk ratios for fracture outcomes in general, although results vary across studies71-77 (Appendix Table 1). For all fractures combined, AUC estimates range from 0.59 to 0.66, and risk ratios range from 1.81 to 2.16 for DEXA of the femoral neck. For QUS, AUC estimates are approximately 0.60, and risk ratios range from 1.26 to 2.25. Similar results were found in 5 studies of men68-70, 73, 78  (Appendix Table 1). For hip fractures specifically, DEXA of the femoral neck is associated with higher risk ratios than QUS for men and women in most studies 70, 72.

Screening Intervals (Key Question 3c)

In a large, good-quality, prospective cohort study (SOF) of 4,124 women 65 years or older, repeated BMD measurement up to 8 years after an initial measurement did not result in statistically significant differences in AUC and risk ratio estimates for nonvertebral, hip, or vertebral fractures79. No studies of screening intervals have been conducted in men or other groups of women.

Efficacy of Medications for Reducing Osteoporosis-Related Fractures (Key Question 5)

Primary Prevention Trials in Postmenopausal Women

Bisphosphonates. Fifteen placebo-controlled RCTs of bisphosphonates met inclusion criteria25, 80-93  (Appendix Table 2). The FIT (Fracture Intervention Trial) met criteria for good quality82. Of 13 trials rated as fair quality, 8 lacked information on randomization, allocation concealment, or outcomes blinding25, 84, 86, 89-93; 5 trials did not report intention-to-treat analysis or blinding of providers80, 81, 85, 87, 88. One poor-quality trial did not report blinding, intention-to-treat analysis, or attrition83.

In 11 trials, mean baseline femoral neck BMD T-scores were -1.0 to -2.580-84, 87-90, 92, 93; 1 trial enrolled women with T-scores less than -2.525; and 3 trials enrolled women with T-scores greater than -1.085, 86, 91. Five trials excluded or did not enroll women with previous vertebral fractures 80-82, 84, 92; 2 trials enrolled more than 20% of participants with previous vertebral fractures but reported results in the subgroup of women without previous fractures25, 87; and the remainder did not report the proportion of women with previous fractures. Only FIT—the large, 4-year trial of alendronate—was designed to evaluate fractures as primary outcomes82.

Bisphosphonates reduced vertebral fractures compared with placebo (relative risk [RR], 0.66 [CI, 0.50 to 0.89]; 7 trials)82, 83, 85, 87-89, 91 (Table 2). Results based on alternative methods for pooling were nearly identical (Appendix Table 3). Including all trials, the absolute risk for vertebral fracture was 1.9% for bisphosphonates versus 3.1% for placebo. Subgroup analyses of individual bisphosphonates were limited by few fractures (range, 0 to 20 events) or drugs other than alendronate. Results were similar in a sensitivity analysis based on a broader definition for primary prevention that added 6 trials (≤40% of participants with previous vertebral fractures or baseline T-scores less than -3.0)22, 24, 87, 101-103.

For total nonvertebral fractures, a pooled analysis of trials indicated no statistically significant effects for bisphosphonates compared with placebo (RR, 0.83 [CI, 0.64 to 1.08]; 9 trials) 82, 85, 86, 88-93 (Table 2). Differences were also not significant for alendronate. Subgroup analyses of other bisphosphonates were limited by few fractures (range, 5 to 18 events). Results for bisphosphonates were statistically significant when estimated using alternative pooling methods (Peto OR, 0.84 [CI, 0.72 to 0.98); fixed-effects Mantel-Haenszel with inverse sample size continuity correction RR, 0.86 [CI, 0.74 to 0.99]) (Appendix Table 3) A sensitivity analysis based on a broader definition for primary prevention described earlier was also statistically significant (RR, 0.82 [CI, 0.69 to 0.96]; 14 trials)22, 24, 82, 85-89, 91-93, 101-103. Results for hip, wrist, or ankle fractures were not statistically significant (Table 2) but were limited by few fractures. For all analyses, estimates that included or excluded trials with 0 events were nearly identical, suggesting that including these trials would have little effect on results.

We could not adequately assess whether estimates of efficacy varied in women according to their mean baseline BMD because only FIT stratified results82. In FIT, for women with baseline femoral neck T-scores less than -2.5, alendronate reduced all types of fractures combined (RR, 0.64 [CI, 0.50 to 0.82]) and vertebral (RR, 0.50 [CI, 0.31 to 0.82)] and hip (0.44 [CI, 0.18 to 0.97]) fractures specifically. For women with T-scores from -1.6 to -2.0 or -2.0 to -2.5, we found nonstatistically significant trends toward reduced vertebral fractures but no effects on all types of fractures combined.

Parathyroid Hormone. A trial of parathyroid hormone evaluated fracture outcomes after 18 months in postmenopausal women with a BMD T-score less than -3.0 and no prevalent vertebral fractures (81% of enrollees) or a T-score less than -2.5 and 1 to 4 prevalent fractures (19%) 94. The trial was considered fair quality because it did not describe blinding of outcomes. In women without previous fractures, parathyroid hormone reduced new vertebral fractures from 2.1% to 0.7% (RR, 0.32 [CI, 0.14 to 0.75]). Among all women, no difference in nonvertebral fractures was found (Table 2).

Raloxifene. The MORE (Multiple Outcomes of Raloxifene) trial included women with BMD T-scores less than -2.5 with or without previous vertebral fractures96, 98, 104. The RUTH (Raloxifene Use for the Heart) trial was designed primarily to determine the effects of raloxifene on coronary events and invasive breast cancer, and fractures were secondary outcomes 97. In a pooled analysis of both trials, raloxifene reduced vertebral (RR, 0.61 [CI, 0.54 to 0.69]) but not nonvertebral (RR, 0.97 [CI, 0.87 to 1.09]) fractures105 (Table 2). In MORE, risk for vertebral fractures was reduced for women with or without previous vertebral fractures 96, 104.

Estrogen. The WHI (Women's Health Initiative) is the largest prevention trial of estrogen (conjugated equine estrogen) with and without progestin (medroxyprogesterone acetate) that reports fracture outcomes in postmenopausal women. Both trials reported reduced clinical vertebral, hip, and all fractures combined compared with placebo99, 100 (Table 2). However, results of both trials were not statistically significant for selective sites, such as the hip, when CIs were adjusted.

Primary Prevention Trials in Men>

The only primary prevention trial for men evaluated the effects of parathyroid hormone in men with osteoporosis (baseline BMD lumbar spine T-scores, -2.0 to -2.4) and met criteria for good quality95. Results indicated a trend toward reduced vertebral (RR, 0.49 [CI, 0.22 to 1.09]) and nonvertebral (RR, 0.51 [CI, 0.10 to 2.48]) fractures with parathyroid hormone, but fractures were few and results did not reach statistical significance95, 106.

Harms Associated With Medications for Osteoporosis and Low Bone Density (Key Question 6)

Bisphosphonates

Although case reports of serious upper gastrointestinal adverse events have been reported with all bisphosphonates, systematic reviews and individual trials found no differences with placebo in rates of serious gastrointestinal adverse events107, 108 or withdrawals109-116 (Appendix Table 4) The FDA recently issued a report that summarized 54 cases of esophageal adenocarcinoma associated with bisphosphonates117.

Evidence on the risk for atrial fibrillation with bisphosphonates is mixed112, 113, 118-121. The FDA issued an interim report of an ongoing review based on data from nearly 20,000 patients treated with bisphosphonates in placebo-controlled trials122. Results indicated no clear association between bisphosphonate exposure and the rate of serious or nonserious atrial fibrillation.

Case reports of severe musculoskeletal pain that may be reversible after discontinuing the medication have been reported with all bisphosphonates. Zoledronic acid was associated with increased musculoskeletal events in a systematic review of trials123. Case reports of osteonecrosis of the jaw are primarily from patients with cancer who receive intravenous doses of bisphosphonates that are higher than doses used for osteoporosis treatment or prevention124. Case reports of atypical, low-energy fractures of the femoral diaphysis in long-term users of alendronate have also been reported, but the incidence is unknown125-127.

Calcitonin and Parathyroid Hormone

Evidence of harms is limited by few trials and inconsistent reporting of adverse events. Calcitonin does not increase risk for the acute coronary syndrome; and calcitonin and parathyroid hormone do not increase risk for cancer or increase mild gastrointestinal events123.

Raloxifene

Raloxifene increases risk for thromboembolic events but not for coronary heart disease, stroke, or endometrial cancer97, 128, 105. It can cause hot flashes, leg cramps, and peripheral edema96, 97, 104. Raloxifene also reduces risk for invasive breast cancer in women without preexisting breast cancer97, 105.

Estrogen

Both estrogen with progestin and estrogen alone increase thromboembolic events129, 130 and strokes 100, 131. Estrogen with progestin increases risk for coronary heart disease events132 and breast cancer133, does not increase risk for endometrial cancer134, and reduces risk for colon cancer135. Estrogen alone did not affect these outcomes in the WHI100, 136, 137.

Discussion

Table 3 summarizes the evidence reviewed for this update, and an outcomes table providing an illustration of the clinical application of the evidence is described in the Appendix and Appendix Table 5 (Also Appendix Figures 3 and 4). No RCTs evaluated the overarching questions of the effectiveness and harms of screening for osteoporosis in reducing fractures and fracture-related outcomes for postmenopausal women and men. Therefore, no direct evidence that screening improves outcomes is available. Support for population screening would be based on evidence that individual risk for fracture can be estimated and fractures can be significantly reduced for persons at risk.

Although many different risk-assessment instruments have been developed, most include similar variables, such as age and weight. Studies that report AUC estimates for validated instruments demonstrate that they are modest predictors of low bone density or fracture, and simpler models perform as well as more complex ones, such as FRAX. No studies determined the effectiveness of these instruments in improving fracture outcomes.

Data from large population-based cohorts indicate that the predictive performance of DEXA is similar for men and women. Calcaneal QUS using various types of devices can predict fractures of the femoral neck, hip, or spine in men and women, although variation exists across studies. Quantitative ultrasonography has low correlation with DEXA, and it is not clear how QUS can be used to select persons for medications that were proven efficacious on the basis of DEXA criteria. Data are lacking to determine how frequently to obtain bone measurements, although 1 study indicated no advantage to repeated measures that were 8 years apart79.

No trials of medications report effects on fracture-related morbidity and mortality. For postmenopausal women, bisphosphonates, parathyroid hormone, raloxifene, and estrogen reduce primary vertebral fractures. Bisphosphonates significantly reduce nonvertebral fractures in sensitivity analyses that used alternative pooling methods or broadened our definition of primary prevention—consistent with meta-analyses of secondary prevention trials of alendronate and risedronate109, 111. Estrogen also reduces nonvertebral fractures in trials when using unadjusted estimates, but results are not statistically significant when estimates are adjusted. In the only primary prevention trial that stratified results according to baseline BMD, benefits were observed only in patients with T-scores of -2.5 or less82. For men, no primary prevention trials of bisphosphonates exist, and results from a single trial of parathyroid hormone did not reach statistical significance.

Trials and safety reviews have not supported consistent associations with serious upper gastrointestinal adverse events, atrial fibrillation, or osteonecrosis of the jaw in otherwise healthy patients taking bisphosphonates for fracture prevention. The FDA has recently highlighted case reports of esophageal cancer and severe musculoskeletal pain. An analysis of data from 3 trials published after our searches found no association between bisphosphonate use and atypical fractures of the subtrochanteric or diaphyseal femur, with an event rate of 2.3 per 10,000 patient-years138. Evidence on harms associated with calcitonin and parathyroid hormone for treatment of osteoporosis is limited. Raloxifene and estrogen with and without progestin increase thromboembolic events; estrogen with and without progestin increases stroke; and estrogen with progestin increases coronary heart disease among older users and breast cancer.

Osteoporotic fractures result from several factors, and this review is limited by its focus on only some of them. Consideration of vision, physical function, risk for falls, and secondary causes of osteoporosis, for example, is also important in reducing fractures. However, these conditions are beyond the scope of this review.

Available evidence is also limited. Trials of medications vary in size, duration, quality, and applicability and have few fracture outcomes. Primary prevention trials and trials that enroll men or persons with low BMD (that is, baseline BMD T-scores from -1.0 to -2.5) are lacking. Applying the results of clinical trials to patient care is especially difficult when selection criteria are rigid and study participants do not represent the community population. This is particularly true in older populations, in which comorbid conditions and use of several medications are common and would disqualify patients from enrolling in most trials.

Osteoporosis and osteoporosis-related fractures are common in aging men and women in the United States. Fractures cause premature mortality, loss of independence and function, reduced quality of life, and substantial financial costs. Although methods to identify persons at risk for osteoporotic fractures are available and medications to reduce fractures are effective, no trials directly evaluate screening effectiveness, harms, and intervals.

Copyright and Source Information

Source: Nelson HD, Haney EM, Dana T, Bougatsos C, Chou R. Screening for osteoporosis: an update for the U.S. Preventive Services Task ForceAnn Intern Med 2010;153(2):1-14.

Disclaimer: The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of the AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

Acknowledgment: The authors acknowledge the contributions of AHRQ Project Officer Kenneth Lin, MD, and USPSTF leads Rosanne Leipzig, MD, PhD; Diana Petitti, MD, MPH; and George Sawaya, MD. Rochelle Fu, PhD, conducted statistical sensitivity analyses; Andrew Hamilton, MLS, MS, created the literature searches; and Michelle Pappas, BA, provided administrative assistance at the Oregon Evidence-based Practice Center at the Oregon Health & Science University.

Grant Support: This manuscript is based on research conducted by the Oregon Evidence-based Practice Center under contract to the AHRQ (contract 290-02-0024). Dr. Haney was supported by a career development award from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (K23 AR051926).

 

Table 1. Performance of Externally Validated Risk-Assessment Instruments*

Instrument or Study
(Reference)
Studies, n Participants, n Components Range of AUC (95% CI)
Instruments that predict low bone density
ABONE 34 1 2365 Age, weight, estrogen use 0.72 (SD, 0.01)
Body weight 33, 34, 37, 38, 47, 48 6 9065 Weight <70 kg 0.13-0.79
DOEScore 52 1 1256§ Age, weight, previous fracture 0.75
Gnudi and Sitta 42 1 1187§ Weight, age at menarche, years since menopause, uses arms to rise from seated position, previous fracture, mother had fracture 0.74
Masoni et al 49 1 195§ BMI, >10 y since menopause, calcium intake <1200 mg/d, previous fracture, kyphosis 0.83 (0.76-0.91)
MORES 60 1 2995§ Age, weight, history of COPD 0.84 (0.81-0.87)
NOF guideline 34, 38, 50 3 3092 Age; weight; previous fracture at age >40 y; current smoker; parent had hip, wrist, or spine fracture age at ≥50 y 0.60-0.70
OPERA 56 1 1522 Age, weight, previous fracture, early menopause, systemic glucocorticoid use Femoral neck, 0.81 (0.79-0.83);
lumbar spine, 0.87
(0.85-0.88)
ORAI 33-35, 37, 38, 43, 44, 48, 50, 55 10 11,093 Age, weight, current estrogen use 0.32-0.84
OSIRIS 37, 44, 48, 51, 58 5 2657 Age, weight, current estrogen use, previous fracture 0.63-0.80
OST 30, 37, 38, 43, 44, 47, 48, 53, 55, 61 10 13,825§ Age, weight 0.33-0.89
SCORE 32, 34, 35, 37, 43, 44, 50, 55, 59 9 13,710 Age, weight, race, rheumatoid arthritis, estrogen use, fracture at age >46 y 0.66-0.87
SOF 32 1 416 Age, current weight less than weight at age 25 y, 13 additional variablesǁ 0.54 (0.48-0.60)
SOFSURF 37 1 208 Age, weight, smoking status, previous postmenopausal fracture 0.72 (0.77-0.67)
Instruments that predict fracture
ABONE 62 1 469 Age, weight, estrogen use Any fracture, 0.63 (0.54-0.71)
Body weight <70 kg
(154 lb) 62
1 469 Weight Any fracture, 0.60 (0.52-0.68)
DOEScore 52 1 1256§ Age, weight, previous fracture 0.48
EPESE 36 1 7654§ Age >75 y; BMI; female; white; previous stroke; cognitive, ADL, or vision impairments; antiepileptic drug use Any fracture, 0.64-0.69; hip fracture, 0.76-0.79
Fracture index (SOF) 31 1 14,461§ Age, weight, fracture at age >50 y, mother had hip fracture at age >50 y, weight ≤57 kg (125 lb), current smoker, uses arms to rise from seated position, total hip BMD T-score Hip fracture, 0.71 with BMD
and 0.77 without BMD
FRAX 39, 40, 46, 57 4 286,499§ Age, BMI, previous fracture, family history of fracture, glucocorticoid use, current smoker, alcohol use of 3 units/d or more, rheumatoid arthritis, hip BMD T-score if available Osteoporotic fracture, 0.54-0.78; hip fracture, 0.65-0.81
Garvan nomogram 57 1 200 Age, sex, femoral neck BMD, body weight, history of fractures at age >50 y, history of falls within the previous 12 mo 0.76-0.84
Minimum data set 41 1 1427§ Age, weight, height, locomotion, recent fall, ADL score,
cognition score, urinary incontinence
Any fracture, 0.63 (0.55-0.71)
ORAI 62 1 469 Age, weight, current estrogen use Any fracture, 0.65 (0.57-0.73)
QFracture 45 1 3,633,812§ Age, BMI, estrogen use, smoking status, daily alcohol use, parental history of osteoporosis, rheumatoid arthritis, cardiovascular disease, type 2 diabetes, asthma, tricyclic antidepressants, corticosteroids, history of falls, menopausal symptoms, chronic liver disease, gastrointestinal malabsorption Any fracture, 0.86-0.89
WHI 54 1 161,808§ Age, weight, self-reported health, height, fracture at age >55 y, race, physical activity, smoking status, parent had hip fracture, corticosteroid or hypoglycemic agent use Hip fracture, 0.80 (0.75-0.85) with BMD; 0.71 (0.66-0.76) without BMD

ABONE = age, body size, no estrogen; ADL = activities of daily living; AUC = area under the curve; BMD = bone mineral density; BMI= body mass index; COPD = chronic obstructive pulmonary disease; DOEScore = Dubbo Osteoporosis Epidemiology Study; EPESE = Established Populations for the Epidemiologic Study of the Elderly; MORES = male osteoporosis risk estimation score; NOF = National Osteoporosis Foundation; OPERA = osteoporosis prescreening risk assessment; ORAI = osteoporosis risk assessment instrument; OSIRIS = osteoporosis index of risk; OST = Osteoporosis Self-assessment Tool; SCORE = simple calculated osteoporosis risk estimation; SOF = Study of Osteoporotic Fractures; SOFSURF = Study of Osteoporosis Fractures—Study Utilizing Risk Factors; WHI = Women's Health Initiative.
* Includes studies of externally validated instruments reporting performance measures with AUC estimates.
† Where provided or calculated for individual study results.
‡ BMD T-score of -2.5 or less.
§ Includes both derivation and validation cohorts.
ǁ Additional variables include first-degree relative who had a hip fracture; previous fracture at age >50 y; no walking for exercise; uses arms to rise from seated position; current use of benzodiazepines, anticonvulsants, or corticosteroids; resting pulse >80 beats/min; on feet <4 h/d; dementia diagnosis; not using menopausal hormone therapy; height ≥5 ft, 7 in, at age 25 y; and race other than black.
¶ Variables used for calculating QFracture score for women but not for men.

Table 2. Fracture Outcomes of Placebo-Controlled Primary Prevention Trials, by Type of Fracture*

Medication Vertebral Nonvertebral
RR (95% CI) Trials, n
(Reference)
RR (95% CI) Trials, n
(Reference)
Bisphosphonates
Alendronate 0.60 (0.44-0.83) 3 82, 83, 87 0.88 (0.55-1.40) 3 82, 86, 90
Combined bisphosphonates 0.66 (0.50-0.89) 7 82, 83, 85, 87-89, 91 0.83 (0.64-1.08) 9 82, 85, 86, 88-93
Parathyroid hormone Women: 0.32 (0.14-0.75);
men: 0.49 (0.22-1.09)
Women: 1 94;
men: 1 95
Women: 0.97 (0.71-1.33);
men: 0.51 (0.10-2.48)
Women: 1 94;
men: 1 95
Raloxifene 0.61 (0.54-0.69) 2 96, 97 0.97 (0.87-1.09) 2 97, 98
Estrogen
Estrogen with progestin 0.66 (0.46-0.92) 1 99 No evidence  
Estrogen alone§ 0.62 (0.42-0.93) 1 100 No evidence  

Table 2 (continued)

Medication Hip Wrist Ankle
RR (95% CI) Trials, n
(Reference)
RR (95% CI) Trials, n
(Reference)
RR (95% CI) Trials, n
(Reference)
Bisphosphonates
Alendronate 0.78 (0.44-1.38) 2 82, 90 0.76 (0.27-2.16) 2 82, 90 0.40 (0.08-2.07) 1 90
Combined bisphosphonates 0.70 (0.44-1.11) 3 25, 82, 90 0.67 (0.25-1.82) 3 82, 90, 93 0.33 (0.08-1.44) 2 90, 93
Parathyroid hormone No evidence   No evidence   No evidence  
Raloxifene 0.97 (0.62-1.52) 1 96 0.83 (0.66-1.05) 1 96 0.94 (0.60-1.47) 1 96
Estrogen
Estrogen with progestin 0.67 (0.47-0.96) 1 99 0.71 (0.69-0.85) 1 99 0.71 (0.69-0.85) 1 99
Estrogen alone§ 0.61 (0.41-0.91) 1 100 No evidence   No evidence  

RR = risk ratio.
* Results for postmenopausal women, unless otherwise indicated.
† Data presented with nominal CIs; adjusted CI for hip (0.41-1.10) and not provided for other sites.
‡Clinical vertebral fractures.
§ Data presented with nominal CIs; adjusted CIs include vertebral (0.34 -1.13) and hip (0.33-1.11).

Table 3. Summary of Evidence

Studies Design Limitations Consistency Applicability Overall Quality
Effectiveness and harms of osteoporosis screening in reducing fractures, morbidity, and mortality (KQs 1 and 4)
No trials          
Performance of risk-assessment instruments to stratify individuals into risk categories (KQ 2)
21 risk-assessment instruments with BMD or fracture outcomes that have external validation and reported AUC estimates Cohort, cross-sectional Most studies are cross-sectional and instruments have not been applied to a prospective clinical population Not consistent Difficult to apply population-determined results to individuals in a clinical setting Fair
Findings: Several risk-assessment instruments have been developed and validated; they are modest predictors of low bone density or fracture; simple models predict as well as complex ones, and none demonstrates superiority over the others.
Performance of DEXA in predicting fractures in men (KQ 3a)
5 studies Prospective cohort Few large studies include men Consistent Population estimates may not apply to individuals Fair to good
Findings: DEXA is not a perfect predictor of fractures, but for each SD reduction in femoral neck BMD, the hazard ratio for various fracture outcomes increases to similar levels for men and women.
Performance of peripheral bone measurement tests in predicting fractures (KQ 3b)
5 studies in men; 7 studies in postmenopausal women Prospective cohort, retrospective cohort, cross-sectional Variability in how measures were used; focus on QUS Consistent Population estimates may not apply to individuals Fair to good
Findings: Calcaneal QUS predicts fractures of the femoral neck, hip, or spine, although variation exists across studies and correlation with DEXA is low.
Screening intervals (KQ 3c)
1 study Prospective cohort Only 1 relevant study in postmenopausal women Not applicable Population estimates may not apply to individuals, particularly those different from the study cohort Fair
Findings: Repeating a BMD measurement up to 8 y after an initial measurement does not significantly improve predictive performance for nonvertebral, hip, or vertebral fractures.
Efficacy of medications for reducing osteoporosis-related fractures (KQ 5)
Women: 15 trials of bisphosphonates, 1 trial of PTH, 2 trials and 1 meta-analysis of raloxifene, 2 trials of estrogen; men: 1 trial of PTH RCTs Strength of evidence varies by medication Consistent Primary prevention trials are most applicable to a screening-detected population Poor to good
Findings: For women, bisphosphonates, PTH, raloxifene, and estrogen reduce vertebral fractures; bisphosphonates reduce nonvertebral fractures in sensitivity analyses; medications are effective for BMD T-scores of -2.5 or less. For men, 1 trial of PTH showed nonsignificant trends for reduced fractures.
Harms associated with medications for osteoporosis and low bone density (KQ 6)
21 studies of bisphosphonates; 1 systematic review of calcitonin and PTH; 5 studies of raloxifene; 8 studies of estrogen RCTs, observational studies, case reports and series Strength of evidence varies by medication Consistent Applicable Poor to good
Findings: Serious GI events, atrial fibrillation, osteonecrosis of the jaw, severe musculoskeletal pain, and esophageal cancer have been reported for bisphosphonates, but the incidence and degree of risk are difficult to estimate for those using them for prevention; raloxifene and estrogen increase thromboembolic events; estrogen increases stroke; and estrogen with progestin increases CHD and breast cancer.

AUC = area under the curve; BMD = bone mineral density; CHD = coronary heart disease; DEXA = dual-energy x-ray absorptiometry; GI = gastrointestinal; KQ = key question; PTH = parathyroid hormone; QUS = quantitative ultrasonography; RCT = randomized, controlled trial.

Appendix Table 1. Recent Studies Comparing Performance of Bone Measurement Tests in Predicting Fractures

Study, Year (Reference) Participants, n Type of Fracture Bone Measurement Test AUC (95% CI or SE) RR for Fracture (95% CI)*
Women
Hans et al, 1996 71 5662 Hip DEXA femoral neck; QUS BUA; QUS SOS Not reported 1.9 (1.6-2.4);
2.0 (1.6-2.4);
1.7 (1.4-2.1)
Bauer et al, 1997 72 6189 Nonvertebral; hip DEXA femoral neck; SXA calcaneus; QUS BUA Not reported 1.3 (1.1-1.5)§;
1.4 (1.2-1.6);
1.3 (1.2-1.5);
2.6 (1.9-3.8)§;
2.2 (1.9-3.0);
2.0 (1.5-2.7)
Khaw et al, 2004 73 8328 All QUS BUA; QUS SOS Not reported 1.90 (1.36-2.66);
1.62 (1.26-2.08)
Alexandersen et al, 2005 74 1034 All DEXA spine; DEXA femoral neck; DEXA distal radius; QUS SOS; QUS UBPI 0.60 (0.56-0.65);
0.66 (0.62-0.71);
0.64 (0.59-0.68);
0.60 (0.56-0.65);
0.60 (0.55-0.64)
 
1.35 (1.19-1.54);
1.81 (1.51-2.16);
1.47 (1.28-1.68);
1.26 (1.12-1.42);
1.55 (1.26-1.90)
Gluër et al, 2005 75 87 Vertebral DEXA spine; QUS SOS; QUS BUA; QUS stiffness Not reported 2.13 (1.08-4.16);
2.58 (1.17-5.68);
2.13 (1.04-4.34);
2.83 (1.26-6.34)
Stewart et al, 2006 76 775 All DEXA lumbar spine; DEXA femoral neck; QUS BUA 0.63 (0.60-0.67);
0.59 (0.56-0.63);
0.62 (0.59-0.66)
 
1.80 (1.17-2.77);
2.16 (1.35-3.47);
2.25 (1.51-3.34)
Frediani et al, 2006 77 1534 Vertebral DEXA spine; DEXA femoral neck; QUS stiffness; QUS stiffness plus DEXA spine; QUS stiffness plus DEXA femoral neck 0.95 (0.3); 0.89 (0.3); 0.93 (0.4); 0.97 (0.2); 0.95 (0.3) 4.18 (3.05-6.82)a;
3.13 (2.76-6.90);
4.18 (3.35-7.13)
Men
Mulleman et al, 2002 68 102 All DEXA lumbar spine; DEXA femoral neck; DEXA hip; QUS BUA; QUS SOS; QUS stiffness 0.80 (0.71-0.88);
0.73 (0.64-0.82);
0.81 (0.71-0.88);
0.69 (0.60-0.78);
0.75 (0.66-0.83);
0.74 (0.65-0.83)
2.8 (1.6-5.0)b;
1.9 (1.1-3.2);
3.4 (1.6-7.0);
1.6 (1.0-2.4);
2.3 (1.4-3.6);
2.1 (1.3-3.3)
Khaw et al, 2004 73 6471 All QUS BUA; QUS SOS Not reported 1.87 (1.23-2.86)**;
1.65 (1.17-2.33)
Gonnelli et al, 2005 69 407 All DEXA hip; QUS stiffness; combined Not reported 3.4 (2.5-4.8);
3.2 (2.3-4.5);
6.1 (2.6-14.3)
Varenna et al, 2005 78 4832 Nonvertebral; hip QUS BUA; QUS SOS; QUS stiffness Not reported

1.38 (1.22-1.59)††;
1.27 (1.17-1.38);
1.14 (0.96-1.40);
2.24 (1.61-3.08)††;
2.19 (1.56-3.11);
1.71 (1.18-3.24)

Bauer et al, 2007 70 5608 Nonvertebral; hip DEXA femoral neck; DEXA hip; QUS BUA; QUS SOS; QUS QUI Not reported

1.6 (1.4-1.9)§;
1.6 (1.4-1.9);
1.6 (1.4-1.8);
1.6 (1.4-1.9);
1.6 (1.4-1.9);
3.5 (2.5-4.9)§;
2.9 (2.2-4.0);
2.0 (1.5-2.8);
2.2 (1.6-3.1);
2.2 (1.6-3.1)

AUC = area under the curve; BMD = bone mineral density; BUA = broadband ultrasound attenuation; DEXA = dual-energy x-ray absorptiometry; QUI = quantitative ultrasound index (combines BUA and SOS); QUS = quantitative ultrasonography measured at the calcaneus in all studies; RR = risk ratio; SOS = speed of sound; SXA = single x-ray absorptiometry; UBPI = ultrasound bone profile index.
* For studies reporting more than 1 type of fracture, results for the first type are provided first, then results for the second type.
† Adapted from the Canadian Agency for Drugs and Technologies in Health Technology Report140. Data from references 71 and 72 included for completeness.
‡ Per SD reduction in BMD or QUS measure, adjusted for age, weight, and clinic center.
§ Per SD reduction in BMD or QUS measure, adjusted for age and clinic.
a Adjusted for years of menopause, weight, height, and body mass index.
b Per SD reduction in BMD or QUS measure.
** Per SD reduction in QUS measure, adjusted for age, previous fracture, smoking status, weight, and height.
†† Per SD reduction in QUS measure, adjusted for age, weight, calcium intake, current smoking status, regular walking outside, bedridden periods >2 mo.

Appendix Figure 1. Analytic Framework and KQs

Text Description is shown below.

KQ = key question.

Text Description.

This figure depicts the analytic framework for screening for osteoporosis. The diagram starts on the left with text that reads "postmenopausal women and men." An arrow then leads to the right; above the arrow appears text that reads "risk factor assessment." Arrow 1, which proceeds up and to the right, represents Key Question (KQ) 1: "Does screening for osteoporosis and low bone density reduce osteoporosis-related fractures and/or fracture-related morbidity and mortality in: a) postmenopausal women younger than 60; women ages 60 to 64 who are at increased risk of osteoporotic fractures; women ages 60 to 64 who are not at increased risk of osteoporotic fractures; women older than 65; and b) men older than 50?" Arrow 1 goes directly to the end of the diagram on the far right.

Arrow 2 represents KQ 2, which is: "What valid and reliable risk assessment instruments stratify women and men into risk categories for osteoporosis or fractures?" Arrow 2 proceeds to the right and forks in two directions. One fork stops at a box labeled "low risk." The other fork proceeds to a box labeled "high risk."

Arrow 3 proceeds from the box and to the right; above the arrow is text that reads "bone measurement testing." Arrow 3 represents KQ 3, which has three parts: 3a) "How well does dual-energy x-ray absorptiometry predict fractures in men?" 3b) "How well do peripheral bone measurement tests predict fractures?" and 3c) "What is the evidence to determine screening intervals for osteoporosis and low bone density?" Arrow 3 then proceeds to the right.

Arrow 4 curves down and ends at an oval labeled "harms." Arrow 4 represents KQ 4: "What are the harms associated with osteoporosis screening?" Arrow 3 then forks in two directions. One fork stops at a box labeled "normal." The other fork proceeds to a box labeled "abnormal." From this box proceeds Arrow 5; above this arrow is text that reads "treatment." Arrow 5 represents KQ 5, which is: "Do medications for osteoporosis and low bone density reduce osteoporosis-related fracture rates and/or fracture-related morbidity and mortality in the target populations?" Arrow 5 then proceeds to the right.

Arrow 6 curves down and ends at an oval labeled "harms." Arrow 6 represents KQ6: "What are the harms associated with medications for osteoporosis and low bone density?" Arrow 5 then proceeds to a box labeled "reduced fractures." From there, the arrow proceeds via a dotted line to the last box of the diagram, labeled "reduced fracture-related morbidity and mortality."

Appendix Table 2. Placebo-Controlled Primary Prevention Trials of Medications

Study, Year (Reference) Participant Characteristics Intervention; Duration Fracture Rates (Drug and Placebo); RR (95% CI) Quality Rating
Vertebral Nonvertebral Hip
Bisphosphonates*
Alendronate
Ascott-Evans et al, 2003 80 Postmenopausal women aged >80 y with 85% of enrollees aged >65 y; mean T-score, -2.3; no previous fractures 10 mg/d; 1 y 0/95 and 0/47; RR not
estimable
0/95 and 0/47; RR not
estimable
NR Fair
Chesnut et al, 1995 81 Women at least 5 y postmenopausal; aged 43-75 y; mean age, 63 y; mean hip T-score, -1.1; no previous fractures 10 mg/d; 2 y 0/30 and 0/31; RR not estimable Unclear NR Fair
FIT 1998 82 Women at least 2 y postmenopausal; mean age, 67.7 y; mean T-score, -2.2; no previous fractures 5 mg/d; 2 y (then 10 mg/d; 2 y) 43/2214 and 78/2218; 0.55 (0.38-0.80) 261/2214 and 294/2218; 0.89 (0.76-1.04) 19/2214 and 24/2218; 0.79 (0.44-1.44) Good
Dursun et al, 2001 83 Postmenopausal women mean age, 61.2 y; mean T-score, -1.5; previous fracture unknown 10 mg/d; 1 y 12/51 and 14/50; 0.84 (0.43-1.63) NR NR Poor
Hosking et al, 1998 86 Women ≥6 mo postmenopausal; mean age, 53.3 y; mean T-score, -0.1; previous fracture unknown 5 mg/d; 2 y 0/498 and 0/502§; RR not estimable 22/498 and 14/502§; 1.58 (0.82-3.06) NR Fair
Liberman et al, 1995 87 ≥5 y postmenopausal; mean age, 64 y; mean T-score, -2.2; 21% with previous vertebral fracture 10 mg/d; 3 y 4/384 and 5/253§; 0.53 (0.14-1.94) NR NR Fair
Pols et al, 1999 90 Women ≥3 y postmenopausal; mean age, 63.0 y; mean T-score, -2.0; unknown previous fracture 10 mg/d; 1 y Not assessed 19/950 and 37/958; 0.52 (0.30-0.89) 2/950 and 3/958; 0.67 (0.11-4.01) Fair
Etidronate
Herd et al, 1997 84 Women 1-10 y postmenopausal; mean age, 54.8 y; mean T-score, -1.3; no previous fracture Cyclical 400 mg/d; 2 y 0/75 and 0/77; RR not estimable NR NR Fair
Meunier, 1997 88 Women 6-60 mo postmenopausal; mean age, 52.7 y; mean T-score, -1.1; unknown previous fracture Cyclical 400 mg/d; 2 y 1/27 and 0/27; 3.00 (0.13-70.53) 2/27 and 3/27; 0.67 (0.12-3.68) NR Fair
Pouilles et al, 199791 Women 6-60 mo postmenopausal; mean age, 53.8 y; mean T-score, -0.8; unknown previous fracture Cyclical 400 mg/d; 2 y 1/54 and 0/55; 3.05 (0.13-73.37) 1/54 and 6/55; 0.51 (0.13-1.93) NR Fair
  Risedronate
Hooper et al, 2005 85 Women 6-36 mo postmenopausal; mean age, 53 y; mean T-score, -0.7; unknown previous fracture 5 mg/d; 2 y 10/129 and 10/125; 0.97 (0.42-2.25) 5/129 and 6/125; 0.81(0.25-2.58) NR Fair
McClung et al, 200125 Mean age, 74 y; mean T-score, -3.7; some women with previous fracture, results reported for women with no baseline fracture (43% of enrollees) 2.5 or 5 mg/d; 3 y NR NR 14/1773 and 12/875; 0.58 (0.27-1.24) Fair
Mortensen et al, 1998 89 Women 6-60 mo postmenopausal; mean age, 51.5 y; mean mean T-score, -1.1; unknown previous fracture 5 mg/d; 2 y (follow-up 3 y) 1/37 and 0/36; 0.97 (CI 0.90-1.05) 0/37 and 3/36; 0.14 (0.01-2.60) 0/37 and 0/36; RR not estimable Fair
Välimäki et al, 2007 93 Women ≥5 y postmenopausal; osteoporosis risk factors or low hip BMD; mean age, 65.9 y; mean T-score, -1.2; unknown previous fracture 5 mg/d; 2 y 0/114 and 0/56; RR not estimable 2/114 and 2/56; 0.49 (0.07-3.40) 0/114 and 0/56; RR not estimable Fair
Zoledronic acid
 Reid et al, 2002 92 Women ≥5 y postmenopausal; mean age, 64.2 y; mean T-score, -1.2; no previous vertebral fracture 4 mg over 1 y in 1-4 infusions; 3 y 0/174 and 0/56; RR not estimable 4/174 and 1/59; 1.36 (0.15-11.89) NR Fair
PTH
Greenspan et al, 2007 94 Postmenopausal women; mean age, 64.4 y; T-score ≤ -3.0 and no prevalent vertebral fractures or T-score, -2.5 with 1 to 4 vertebral fractures; mean T-score, -2.2; 19% with previous vertebral fracture PTH, 100 µg daily injection; 18 mo 7/1050 and 21/1011; 0.32 (0.14-0.75); for those without baseline fracture 72/1286 and 72/1246; 0.97 (0.71-1.33); for all participants NR Fair
Orwell et al, 2003 95 Men; mean age, 59 y; mean T-score, -2.7; unknown previous fracture Teriparatide, 20 or 40 µg daily injection; 11 mo NR 2/151 (20 µg), 1/139 (40 µg), and 3/147 (placebo) NR Good
Selective estrogen receptor modulators
MORE, 2002, 2005, 1999 96, 98, 104 Postmenopausal women; median age, 66.9 y; mean femoral neck or lumbar spine T-score, -2.57; 37% with previous vertebral fractures Raloxifene, 60 or 120 mg/d; 4 y 169/2259 (60 mg), 159/2277 (120 mg), and 287/2292 (placebo); 0.64 (0.63-0.76)(60 mg) and 0.57 (0.48-0.69) (120 mg) 548/4536 (both doses combined) and 296/2292; 0.93 (0.81-1.06) 56/4536 (both doses combined) and 29/2292; 0.97 (0.62-1.52) Good
RUTH, 2006, 2008 97, 141 Postmenopausal women with heart disease or risk factors; median age, 67.5 y; unknown previous fracture Raloxifene, 60 mg/d; 5.6 y 6/5044 and 97/5057; 0.65 (0.47-0.89) 428/5044 and 438/5057; 0.96 (0.84-1.09) NR Good
Estrogen
WHI, 2003 99 Postmenopausal women; mean age, 63.3 y; mean lumbar spine T-score, -1.28 in subset; 14% with previous fractures after age 55 y CEE, 0.625 mg/d, plus MPA, 2.5 mg/d; 5.6 y 41/8506 and 60/8102; 0.65 (nCI, 0.46-0.92) Wrist fracture, 189/8506 and 245/8102; 0.71 (nCI, 0.59-0.85) 52/8506 and 73/8102; 0.67 (nCI, 0.47-0.96; aCI, 0.41-1.10) Fair
WHI, 2004 100 Postmenopausal women; mean age, 63.6 y; unknown BMD; 12% with previous fracture CEE, 0.625 mg/d; 6.8 y 39/5310 and 64/5429; 0.62 (nCI, 0.63-0.79; aCI, 0.34-1.13) NR 38/5310 and 64/5429; 0.61 (nCI, 0.41-0.91; aCI, 0.33-1.11) Fair

aCI = adjusted CI; BMD = bone mineral density; CEE = conjugated equine estrogen; FIT = Fracture Intervention Trial; MORE = Multiple Outcomes of Raloxifene Evaluation; MPA = medroxyprogesterone acetate; nCI = nominal CI; NR = not reported; PTH = parathyroid hormone; RR = relative risk; RUTH = Raloxifene Use for the Heart; WHI = Women's Health Initiative.
* BMD T-scores for bisphosphonate trials are based on femoral neck measurements and calculated by using the FRAX patch instrument, unless stated otherwise.
† Clinical vertebral fractures only.
‡ Per SD reduction in BMD or QUS measure, adjusted for age, weight, and clinic center.
§ Subgroup of women with no previous vertebral compression fractures.

Appendix Figure 2. Literature Search and Selection

Text Description is shown below.

KQ = key question; USPSTF = U.S. Preventive Services Task Force.

*Cochrane databases include the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews.
† Identified from reference lists and suggested by experts.
‡ Some abstracts and articles were considered for more than 1 KQ.
§ Additional articles are described in the technical report)19.

Text Description.

This figure is a flow chart depicting the selection of articles for this review. The chart begins with "Abstracts of potentially relevant articles identified through MEDLINE, Cochrane, and other sources (n = 3858)*†"; Excluded abstracts (n = 3321). The next step is "Full-text articles reviewed with inclusion and exclusion criteria for relevance to the KQs (n = 537)‡." Excluded articles (n = 380):

Wrong population: 22.
Wrong intervention: 9.
Wrong outcome: 49.
Wrong study design: 60.
Wrong publication type: 69.
Non-English language, but otherwise relevant: 1.
Methodological issue: 2.
Covered by a systematic review, previous USPSTF report, or other included paper: 152.
Did not meet definition of primary prevention: 16.

Included articles§:

KQ1: Screening Effectiveness: No evidence.
KQ2: Risk-Assessment Instruments: 21 risk-assessment instruments (in 33 articles).
KQ3: Screening Tests and Intervals:
   KQ3a: 5 studies (in 6 articles).
   KQ3b: 11 studies.
   KQ3c: 1 study.
KQ4: Screening Harms: No evidence.
KQ5: Treatment Efficacy
   Women
        Bisphosphonates: 15 trials.
        Parathyroid hormone: 1 trial.
        Raloxifene: 2 trials (in 4 articles) and 1 meta-analysis.
        Estrogen: 2 trials.
   Men
        Parathyroid hormone: 1 trial (2 articles). KQ6: Treatment Harms:
   Bisphosphonates: 21 studies, including case reports.
   Calcitonin, parathyroid hormone: 1 systematic review.
   Raloxifene: 5 studies.
   Estrogen: 8 studies (in 10 articles)

Appendix Table 3. Sensitivity Analysis for Trials With Few, Rare, or 0 Fracture Events

Alternative Method Fracture Outcome (95% CI)
Vertebral Nonvertebral Hip Wrist Ankle
Arcsine difference, 0 event trials included -0.03 (-0.05 to 0.00) -0.03 (-0.05 to 0.00) -0.01 (-0.04 to 0.02) -0.01 (-0.04 to 0.03) -0.03 (-0.09 to 0.02)
Arcsine difference, 0 event trials excluded -0.03 (-0.06 to -0.01) -0.03 (-0.05 to 0.00) -0.01 (-0.04 to 0.02) -0.01 (-0.04 to 0.03) -0.03 (-0.09 to 0.02)
0 event trials excluded

Mantel-Haenszel relative risk, random-effects model, constant continuity correction (added 0.5 to each group)

0.66 (0.49 to 0.89) 0.83 (0.64 to 1.08) 0.78 (0.44 to 1.38) 0.67 (0.25 to 1.82) 0.33 (0.08 to 1.44)

Peto odds ratio

0.63 (0.47 to 0.84) 0.84 (0.72 to 0.98) 0.78 (0.44 to 1.38) 1.05 (0.78 to 1.41) 0.33 (0.08 to 1.35)

Mantel-Haenszel relative risk, fixed-effects model, variable continuity correction (added inverse of the sample size in the opposite treatment group)

0.65 (0.49 to 0.85) 0.86 (0.74 to 0.99) 0.78 (0.44 to 1.38) 1.03 (0.77 to 1.38) 0.32 (0.07 to 1.49)

Appendix Figure 3. Number of Women Needed to Screen to Prevent One Fracture in 5 Years

Text Description is shown below.

Text Description.

This figure is a graph depicting the number of women who need to undergo screening to prevent one osteoporosis-related fracture in 5 years. The horizontal axis represents the woman's age in years. There are five categories: women ages 55 to 59; women ages 60 to 64; women ages 65 to 69; women ages 70 to 74; and women ages 75 to 79. The vertical axis represents the number of women needed to screen, and it ranges from 0 to 1,800 in increments of 200.

The data points connected by the dotted line correspond to the number of women who need to be screened to prevent one case of hip fracture. The line begins with about 1,700 women needing to be screened between the ages of 55 and 59 and gradually decreases to about 300 women needing to be screened after the age of 75.

The data points connected by the dashed line correspond to the number of women who need to be screened to prevent one case of vertebral fracture. The line begins with about 700 women needing to be screened between the ages of 55 and 59 and gradually decreases to about 100 women needing to be screened after the age of 75.

The data points connected by the solid line correspond to the number of women who need to be screened to prevent one case of clinical fracture. The line begins with about 300 women needing to be screened between the ages of 55 and 59 and gradually decreases to about 50 women needing to be screened after the age of 75.

Appendix Table 4. Adverse Health Outcomes from Studies, by Medication

Adverse Outcome Evidence
Bisphosphonates
Withdrawals No differences with placebo for alendronate 111, etidronate 110, risedronate 109, zoledronic acid 112-113, and ibandronate 114-116.
Gastrointestinal events Mild upper gastrointestinal events (acid reflux, esophageal irritation, nausea, vomiting, and heartburn) were associated with etidronate and pamidronate in meta-analyses of trials 123; however, several trials were conducted before current preventive dosing measures were widely practiced and may not be relevant. No associations were with alendronate, ibandronate, risedronate, or zoledronic acid. Serious events, including esophageal ulcerations, have been reported for all bisphosphonates, although some trials predate preventive measures 107 and another uses a noncomparable control group 108. Esophageal adenocarcinoma was reported by the FDA in 54 cases of bisphosphonate users 117.
Atrial fibrillation Data from the HORIZON trial of zoledronic acid 112, FIT of alendronate 118, and a meta-analysis of risedronate trials 119 suggest associations with severe atrial fibrillation. Observational studies of alendronate and etidronate reported conflicting results 120-121. A report from the FDA based on data from nearly 20,000 patients treated with bisphosphonates in placebo-controlled trials found no associations with atrial fibrillation 122.
Musculoskeletal symptoms Zoledronic acid was associated with increased muscular and joint pain, arthritis, and muscle cramps (RR, 4.52 [95% CI, 3.48-5.43]; 3 trials) 123. Severe reversible musculoskeletal pain has been reported for all bisphosphonates.
Osteonecrosis of the jaw A report from the FDA described 151 case reports of osteonecrosis of the jaw through 2003 124. Of these, 139 occurred in patients with cancer who used high-dose intravenous pamidronate or zoledronic acid and in 12 patients who used alendronate.
Parathyroid hormone
Cancer No association (RR, 0.49 [CI, 0.27-0.90]; 3 trials) 123.
Mild gastrointestinal events No association (RR, 1.39 [CI, 0.98-2.00]; 2 trials) 123.
Calcitonin
Acute coronary syndrome No association (RR, 0.98 [CI, 0.07-13.7]; 3 trials) 123.
Cancer No association 123.
Mild gastrointestinal events No association (RR, 0.96 [CI, 0.63-1.48]; 15 trials) 123.
Raloxifene
Thromboembolic events Increased (RR, 1.60 [CI, 1.15-2.23]; 2 trials) 105.
Coronary heart disease No association (RR, 0.95 [CI, 0.84-1.06]; 2 trials) 105.
Stroke No association (RR, 0.96 [CI, 0.67-1.38]; 2 trials) 05.
Breast cancer Reduced risk for invasive breast cancer in older women without preexisting cancer (RR, 0.44 [CI, 0.27-0.71]; 2 trials) 105.
Endometrial cancer No association (RR, 1.14 [CI, 0.65-1.98]; 2 trials) 129.
Others Increased vasomotor symptoms and leg cramps 105.
Estrogen
Thromboembolic events Increased with E + P (RR, 2.06 [CI, 1.57-2.70]) 129; results for E-alone were not statistically significant when all events were combined (RR, 1.32 [CI, 0.99-1.75]) 130 but were increased for DVT (RR, 1.47 [CI, 1.06-2.06]) and PE (RR, 1.37 [CI, 1.12-4.40]) when evaluated separately in the WHI 130.
Coronary heart disease Increased with E + P (RR, 1.24 [CI, 1.00-1.54]) 132 but not with E-alone (RR, 0.95 [CI, 0.79-1.16]) 136 in the WHI. Women starting E + P within 10 y from the onset of menopause had reduced risk compared with those starting later 142.
Stroke Increased with E + P (RR, 1.31 [CI, 1.02-1.68]) 131 and E-alone (RR, 1.39 [CI, 1.10-1.77]) 100 in the WHI.
Breast cancer Increased with E + P (RR, 1.24 [CI, 1.01-1.54]) 133 but not with E-alone (RR, 0.80 [CI, 0.62-1.04]) 137 in the WHI.
Endometrial cancer No association with E + P (RR, 0.81 [CI, 0.48-1.36]) 134 in the WHI.
Others Decreased colon cancer with E + P (RR, 0.54 [CI, 0.36-0.82]) 135, but not E-alone (RR, 1.08 [CI, 0.75-1.55]) 100 in the WHI. Increased vaginal bleeding.

DVT = deep venous thrombosis; E-alone = estrogen without concomitant use of progestin; E + P = estrogen and concomitant use of progestin; FDA = U.S. Food and Drug Administration; FIT = Fracture Intervention Trial; HORIZON = Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly (HORIZON) Pivotal Fracture Trial; PE = pulmonary embolism; RR = risk ratio; WHI = Women's Health Initiative.
† Adjusted CI, 0.97-1.60.
‡ Adjusted CI, 0.97-1.99.

Appendix Figure 4. Ten-Year Risks for Major Osteoporotic and Hip Fractures for U.S. White Women Estimated from the Online FRAX Calculator

Text Description is shown below.

Major osteoporotic fractures include hip, clinical vertebral, proximal humerus, and distal forearm. Highlighted risks equal or exceed the reference case (woman aged 65 years with no risk factors: 9.3% for osteoporotic fracture; 1.2% for hip fracture). BMI = body mass index.
* Normal BMI = 25.0 kg/m2 based on average height of 163 cm (64.17 in) and weight of 66.5 kg (146.61 lb). Low BMI = 21.2 kg/m2 based on average height of 163 cm (64.17 in) and weight of 56.7 kg (125 lb).
† Daily alcohol use of 3 or more units/d (approximately 3 oz each).

Text Description.

This figure depicts a woman's risk of having a major osteoporotic or hip fracture in the next 10 years, based on her age and risk factors. The risk is calculated using FRAX, the World Health Organization's risk assessment tool for osteoporosis. The results are grouped on the basis of the number and type of risk factors present.

Appendix Table 5. Screening Outcomes for Women Without Previous Vertebral Fractures*

Variable Age
55-59 y 60-64 y 65-69 y 70-74 y 75-79 y
Assumptions
Number undergoing screening 10,000 10,000 10,000 10,000 10,000
Prevalence of osteoporosis (T-score of -2.5 or less) 0.0445 0.0650 0.1200 0.2025 0.2850
RR for clinical fracture with alendronate (CI, 0.50-0.82) 0.64 0.64 0.64 0.64 0.64
RR for vertebral fracture with alendronate (CI, 0.31-0.82) 0.50 0.50 0.50 0.50 0.50
RR for hip fracture with alendronate (CI, 0.18-0.97) 0.44 0.44 0.44 0.44 0.44
Outcomes, n
Cases of osteoporosis identified (10,000 X prevalence) 445 650 1200 2025 2850
Clinical fractures expected with no therapy (24.50%) 109 159 294 496 698
Clinical fractures expected with therapy (16.38%) 73 106 197 332 467
Clinical fractures prevented 36 53 97 164 231
Vertebral fractures expected with no therapy (7.25%) 32 47 87 147 207
Vertebral fractures expected with therapy (3.63%) 16 24 44 74 103
Vertebral fractures prevented 16 23 43 73 104
Hip fractures expected with no therapy (2.75%) 12 18 33 56 78
Hip fractures expected with therapy (1.25%) 6 8 15 25 36
Hip fractures prevented 6 10 18 31 42
Number needed to screen to prevent 1 fracture over 5 y
Clinical fracture 278 187 103 61 43
Vertebral fracture 625 435 233 137 96
Hip fracture 1667 1000 556 323 238

RR = risk ratio.
* Assumptions based on population estimates and results of the Fracture Intervention Trial for women with T-score of -2.5 or less.
† From reference 139.
‡ From results of the Fracture Intervention Trail for women with a BMD T-score of the femoral neck of -2.5 or less82. Event rates have been recalculated for 5 y.

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Current as of: July 2010

Internet Citation: Evidence Summary: Osteoporosis: Screening. U.S. Preventive Services Task Force. October 2014.
https://www.uspreventiveservicestaskforce.org/Page/Document/evidence-summary6/osteoporosis-screening

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