Guidelines Issued for Screening Men for Osteoporosis

Guidelines Issued for Screening Men for Osteoporosis  CME/CE

News Author: Laurie Barclay, MD
CME Author: Laurie Barclay, MD
Disclosures

Release Date: May 5, 2008; Valid for credit through May 5, 2009

Credits Available

Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™ for physicians; Family Physicians - up to 0.25 AAFP Prescribed credit(s) for physicians; Nurses - 0.25 nursing contact hours (None of these credits is in the area of pharmacology)

To participate in this internet activity: (1) review the target audience, learning objectives, and author disclosures; (2) study the education content; (3) take the post-test and/or complete the evaluation; (4) view/print certificate View details.

Learning Objectives

Upon completion of this activity, participants will be able to:

1. Describe risk factors for osteoporosis in men.
2. Describe key recommendations for osteoporosis screening in men.

Authors and Disclosures

Laurie Barclay, MD
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

Brande Nicole Martin
Disclosure: Brande Nicole Martin has disclosed no relevant financial information.

 

May 5, 2008 — The American College of Physicians (ACP) has issued new clinical practice guidelines for screening men for osteoporosis, which are published in the May 6 issue of the Annals of Internal Medicine, along with a systematic review of the evidence. The new guidelines recommend that clinicians assess risk factors for osteoporosis in older men and that clinicians obtain a dual-energy x-ray absorptiometry (DXA) scan for men at increased risk for osteoporosis who are candidates for drug therapy.

"Older men, especially those over the age of 65, need to be assessed regularly for risk factors for osteoporosis," lead author Amir Qaseem, MD, PhD, MHA, a senior medical associate in ACP's Clinical Programs and Quality of Care Department, says in a news release. "Osteoporosis is not just a women's disease."

Osteoporosis, which is characterized by low bone mass and structural deterioration of bone tissue, results in bone fragility and increased risk for hip, spine, and wrist fractures. The prevalence of osteoporosis is currently estimated to be 7% in white men, 5% in African American men, and 3% in Hispanic American men.

Supporting Dr. Qaseem's statement that osteoporosis is not just a women's health issue are rising rates of osteoporosis among men, which are projected to increase by nearly 50% during the next 15 years, with rates of hip fracture expected to double by 2040.

The National Osteoporosis Foundation has recommended that men 70 years of age and older undergo bone mineral density (BMD) testing. Also, BMD testing is recommended in postmenopausal women and men aged 50 to 70 years when the patient's risk factor profile indicates potential problems. And, in those who have had a fracture, BMD testing is recommended to assess the severity of the fracture.

The evidence to date shows that osteoporotic fractures are associated with significant morbidity and mortality in men, resulting in substantial disease burden, death, and healthcare costs. For men, the 1-year mortality rate after hip fracture is twice that in women.

The guidelines are based on a systematic review of evidence from previously published studies, authored by Hau Liu, MD, MBA, MPH, and colleagues. The reviewers searched MEDLINE from 1990 to July 2007 for articles that evaluated risk factors for osteoporotic fracture in men or that evaluated a non-DXA screening test against a gold standard of DXA. They also searched references of previous reviews and solicited articles from experts.

Two reviewers independently abstracted data from each article, assessed performance characteristics of the screening tests, and evaluated the quality of 167 studies included in the meta-analysis.

Based on this meta-analysis, risk factors for low BMD–related fracture in men and women were age (> 70 years), body mass index (BMI) less than 20 to 25 kg/m², weight loss of more than 10%, physical inactivity or sedentary lifestyle, previous osteoporotic fractures not resulting from significant trauma, prolonged or ongoing use of certain drugs (eg, prednisone or other corticosteroids), and low-calcium diet.

In men, androgen deprivation therapy and spinal cord injury were also associated with the risk for osteoporosis.

The reviewers also looked at 102 additional studies evaluating 15 other potential risk factors, but data in men were too limited to allow firm conclusions.

Based on 20 articles reporting on diagnostic studies and use of a T-score threshold of –1.0, calcaneal ultrasonography had a sensitivity of 75% and a specificity of 66% for osteoporosis diagnosed with DXA as the gold standard. Sensitivity for osteoporosis detected with DXA was 81%, and specificity was 66% for the Osteoporosis Self-Assessment Screening Tool, with use of a risk score threshold of –1.

The reviewers concluded that non-DXA tests were either insufficiently sensitive or were lacking sufficient data to draw firm conclusions regarding their value for screening.

Limitations of this review were paucity of data on radiography, bone geometry variables, and other screening tests.

Based on this review, the ACP issued the following recommendations:

1. Clinicians should periodically evaluate older men for risk factors for osteoporosis, using an individualized assessment (grade: strong recommendation; moderate quality evidence).
2. For men who are at increased risk for osteoporosis and who are candidates for drug therapy, a DXA scan should be performed (grade: strong recommendation; moderate quality evidence).
3. The ACP also recommends additional research to evaluate osteoporosis screening tests in men.

"Osteoporosis. . . is significantly underdiagnosed and undertreated in men," Dr. Qaseem says. "Not enough older men are being screened."

One of the authors of the ACP guidelines has disclosed various financial relationships with the US Centers for Disease Control and Prevention, Atlantic Philanthropies, United Health Foundation, Bristol-Myers Squibb, Novo Nordisk, Endopharm, Boehringer Ingelheim, and Sanofi Pasteur.

The systematic review by Liu and colleagues was supported by the US Department of Veterans Affairs Health Services Research and Development Evidence Synthesis Activity Pilot Program. Dr. Liu was supported by an Agency for Healthcare Research and Quality National Research Service Award. A complete list of disclosures is available in the review by Liu and colleagues.

Ann Intern Med. 2008;148:680-684, 685-701.

Clinical Context

During the next 15 years, rates of osteoporosis among men are projected to increase by nearly 50%, and by 2040, rates of hip fracture in men are expected to double. Previous studies have shown that osteoporotic fractures are linked to significant morbidity and mortality in men, with 1-year mortality rate after hip fracture twice that of women.

Previous guidelines and systematic reviews have addressed management of osteoporosis in women, but the US Preventive Services Task Force has not issued guidelines for screening for osteoporosis in men. The only existing recommendation before the ACP issued the present guidelines regarding osteoporosis screening in men was issued by the National Osteoporosis Foundation. That group has recommended that men 70 years of age and older undergo BMD testing.

Study Highlights

• The evidence base for this review came from a search of MEDLINE from 1990 to July 2007 as well as references of previous reviews and articles solicited from experts.
• Inclusion criteria for studies were those that investigated risk factors for osteoporotic fracture in men or that compared a non-DXA screening test against a gold standard of DXA.
• 2 reviewers independently abstracted data from each article, determined performance characteristics of the screening tests, and assessed the quality of included studies.
• The meta-analysis included 167 studies.
• In men and women, risk factors for low BMD–related fracture were age (> 70 years), BMI less than 20 to 25 kg/m², weight loss of more than 10%, physical inactivity, previous osteoporotic fractures not resulting from significant trauma, prolonged use of prednisone or other corticosteroids, and low-calcium diet.
• Other factors associated with the risk for osteoporosis in men were androgen deprivation therapy and spinal cord injury.
• Although the reviewers also examined 102 other studies evaluating 15 other potential risk factors, data in men were too limited to allow firm conclusions.
• Based on 20 articles reporting on diagnostic studies and use of a T-score threshold of –1.0, calcaneal ultrasonography had a sensitivity of 75% and a specificity of 66% for osteoporosis diagnosed with DXA as the gold standard.
• For the Osteoporosis Self-Assessment Screening Tool, sensitivity for osteoporosis detected with DXA was 81% and specificity was 66% with use of a risk score threshold of –1.
• The reviewers concluded that non-DXA tests were either insufficiently sensitive or were lacking sufficient data to draw firm conclusions about their screening value.
• Limitations of this review were few data on radiography, bone geometry variables, and other screening tests.
• Based on this review, the ACP issued the following recommendations:
  • Using an individualized assessment, clinicians should periodically evaluate older men for risk factors for osteoporosis (grade: strong recommendation; moderate quality evidence).
  • DXA scan should be performed in men who are at increased risk for osteoporosis and are candidates for drug therapy (grade: strong recommendation; moderate quality evidence).
  • The ACP also recommends additional research to evaluate osteoporosis screening tests in men.

Pearls for Practice

• Risk factors for low BMD–related fracture and osteoporosis in men were age older than 70 years, BMI less than 20 to 25 kg/m², weight loss of more than 10%, physical inactivity, previous osteoporotic fractures not resulting from significant trauma, prolonged use of prednisone or other corticosteroids, low-calcium diet, androgen deprivation therapy, and spinal cord injury.
• The ACP has recommended that clinicians periodically evaluate older men for risk factors for osteoporosis using an individualized assessment, men at increased risk for osteoporosis who are candidates for drug therapy have a DXA scan, and additional research to evaluate osteoporosis screening tests in men be conducted.