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骨质疏松筛查 JAMA 杂志

Screening for Osteoporosis

Diane Altkorn,MD;Adam S.Cifu,MD

Summary of the Clinical Problem

The prevalence of osteoporosis in persons older than 50years in the United States is estimated to be 16%of women (about 8.6million individuals)and 4%of men (about 1.6million individuals).1In the United States,more than 1.5million fractures per year are related to osteoporosis,including an estimated 300000hip and 700000vertebral fractures.2Many patients who develop fractures experi-ence a decrease in functional status,with up to one-third of pa-tients entering nursing facilities within 1year after a hip fracture;the mortality rate after hip fracture may exceed 20%in the first year.3Low bone density is the primary risk factor for osteoporotic frac-tures,and treatment of patients with low bone density can prevent fractures.3

Characteristics of the Guideline Source

Founded in 1984,the NOF focuses on research,education,and advocacy regarding osteoporosis.Since 1990,the NOF has part-nered with the International Osteoporosis Foundation to publish the journal Osteoporosis International ,and the NOF has issued guidelines since 1998.The current guideline 4was developed by a multispecialty committee of experts representing the NOF,the American Society for Bone and Mineral Research,and the Interna-tional Society for Clinical Densitometry (ISCD)(Table ).Specialists in endocrinology,rheumatology,and geriatrics served as consul-tants for the 2014update.The guideline has been endorsed by the American Academy of Pain Medicine,the American Society for Bone and Mineral Research,the ISCD,and the American Asso-ciation of Clinical Endocrinologists.All contributors disclosed any real or apparent interest that could have bearing on the subject

matter,including relationships with manufacturers of any com-mercial products.All potential conflicts were resolved to the sat-isfaction of the NOF.

Evidence Base

There are no controlled studies that have shown that screening for osteoporosis reduces fractures or fracture-related morbidity or mortality;thus,the screening recommendations are based on extrapolation from studies of drug therapy in women with osteo-porosis that have shown a reduction in vertebral fractures with treatment (relative risk [RR],0.66[95%CI,0.50-0.89]for bis-phosphonates vs placebo;RR,0.61[95%CI,0.54-0.69]for ralox-ifene vs placebo).3A pooled analysis of 9trials did not show a sta-tistically significant association between

bisphosphonate

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treatment and reduced nonvertebral fractures(RR,0.83;95%CI, 0.64-1.08).5

The recommendation to screen men is based on the Endo-crine Society guidelines.The Endocrine Society used data from a meta-analysis of risk factors for fracture in men.The evidence was gradedas“verylowquality,”notingthatmostoftheassociationswere weak,with odds ratios less than2.6

The recommendation for vertebral imaging is based on mul-tiple studies showing a substantially increased risk of subsequent fracture in patients with vertebral fractures,one of which found a higher than4-fold risk in patients with a single vertebral fracture(RR, 4.4;95%CI,3.6-5.4);another study found nearly a12-fold risk in those with2vertebral fractures at baseline examination(RR,11.8; 95%CI,5.1-26.8).7,8Other studies have found that only one-third of vertebral fractures are detected clinically,and these fractures fre-quently occur in patients who would not be treated based on BMD results alone.A historical height loss(the difference between the pa-tient’s highest recalled height and current measured height)greater than4cm is associated with a3-fold increase in vertebral fracture (RR,2.9;95%CI,2.6-3.3;absolute risk,33%).9Pharmacologic therapy has been shown to reduce vertebral fractures,and cost-effectiveness analyses suggest that screening with vertebral imaging is cost-effective.10

Benefits and Harms

Multiple randomized trials and meta-analyses have shown that treat-ment of patients with osteoporosis reduces fracture rates.The NOF has performed cost-effectiveness analyses,determining that it is cost-effective to treat a patient when the10-year risk of hip frac-tureis3%ormore(asdeterminedbytheFRAXcalculator).Theharms of treatment vary based on the adverse effects of the drug used.The screening test is not harmful.

Discussion

There are several other published guidelines on this topic.All major groups,including the US Preventive Services Task Force (USPSTF),recommend universal screening for osteoporosis for postmenopausal women aged65years or older and for post-menopausal women younger than65years with increased risk as variably defined;doing so should be considered standard prac-tice.(Multiple tools have been developed to predict fracture risk, with the FRAX calculator one of the most widely used.The USP-STF systematic review reported that FRAX has an area under the curve of0.54to0.78for osteoporotic fractures and0.65to0.81 for hip fractures.3)The USPFTF found insufficient evidence to recommend for or against screening for osteoporosis in men; although the NOF,Endocrine Society,and ISCD do recommend screening men aged70years or older,the evidence supporting this recommendation is weak.The USPSTF does not address ver-tebral fracture screening.

Areas in Need of Future Study or Ongoing Research

It may not be feasible to conduct a randomized trial of BMD screen-ing in postmenopausal women.A randomized trial of screening in older men would clarify the magnitude of benefit in the male popu-lation.Although the evidence supporting vertebral fracture screen-ing is compelling,it would be strengthened by a randomized trial that confirmed and quantified the apparent benefit.Better validated and more accurate risk calculators are needed.

ARTICLE INFORMATION

Author Affiliations:Section of General Internal Medicine,University of Chicago,Chicago,Illinois (Altkorn);Department of Medicine,University of Chicago,Chicago,Illinois(Cifu).

Corresponding Author:Adam S.Cifu,MD, Department of Medicine,University of Chicago, 5841S Maryland Ave,MC3051,Chicago,IL60637 (adamcifu@https://www.wendangku.net/doc/5615425745.html,).

Section Editor:Edward H.Livingston,MD,Deputy Editor,JAMA.

Conflict of Interest Disclosures:The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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