Osteoporosis: Diagnosis and Managements _ _____________________________________________________
RISK ASSESSMENT TOOLS Assessment tools that may be used to determine a patient’s osteoporosis risk include the Osteoporosis Risk Assessment Instrument (ORAI), the Simple Calculated Osteoporosis Risk Estimation (SCORE), and the WHO Fracture Risk Assessment Tool (FRAX). The ORAI is a simple, three-item tool based on age, weight, and current hormone use. The SCORE tool combines six risk factors, including age, weight, race, estrogen use, presence of rheumatoid arthritis, and fracture history. A Canadian study using DXA of the hip as the standard for diagnosing osteoporosis (T-score below -2.5) found that the ORAI had a sensitivity of 97.5% and a specificity of 28%. In the same study, the SCORE tool had a higher sensitivity, at 99.6%, but a lower specificity, at 18% [45]. A systematic review of SCORE, ORAI, and the Osteoporosis Self-assessment Tool (OST) found SCORE and OST to have a higher sensitivity for predicting major osteoporotic fracture in women 65 years of age and older [46]. The OST uses age and weight as parameters to predict the risk of osteoporosis and has been found to be superior in identifying men at risk of osteoporosis or osteoporotic fractures [47; 48]. FRAX is a web-based tool that assesses the 10-year risk of a major osteoporosis fracture in women and men. Individual risk factors (i.e., age, sex, weight, height, and femoral neck BMD, if available) and clinical risk factors (i.e., prior fragility fracture, parental history of hip fracture, current tobacco use, long-term glucocorticoid use, rheumatoid arthritis, daily alcohol consumption, and secondary causes of osteoporosis) are entered into the web tool, which calculates and provides a 10-year fracture probability (as a percentage) of absolute, rather than relative, risk (as occurs on the output of DXA equipment) [43]. The BHOF has outlined U.S.-specific considerations for the application and use of FRAX [20]. The 2020 American Association of Clinical Endocrinologists and American College of Endocrinology (AACE/ACE) clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis recommend use of the FRAX algorithm as part of the initial evaluation and for guiding treatment decisions [49]. SCREENING GUIDELINES Routine BMD screening has been recommended for women 65 years of age and older, regardless of risk, and for women 50 to 69 years of age with clinical risk factors for fracture (e.g., low body weight, prior fracture, high risk medication use, disease or condition associated with bone loss) [20; 33; 35; 50; 51]. The ISCD and BHOF also have recommended routine screening for men 70 years of age and older, regardless of risk factors, and for men 50 to 69 years of age when concerns exist about the patient’s risk factor profile (e.g., low body weight, prior fracture, high risk medication use, disease or condition associated with bone loss) [20; 33]. The U.S. Preventive Services Task Force (USPSTF) has determined that the evidence is insufficient to recommend for or against routine screening for osteoporosis in men [50]. Additional recommendations for BMD screening include [20; 33; 35; 50; 51]:
• Adults being considered for pharmacologic therapy for osteoporosis • Women in menopausal transition with risk factors for fracture • Adults 50 years of age and older with fragility fracture • Adults with disease/conditions associated with low bone mass/bone loss • Anyone not receiving therapy in whom evidence of bone loss would lead to treatment
The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older and
postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool. (https://jamanetwork.com/journals/jama/fullarticle/ 2685995. Last accessed October 15, 2024.) Strength of Recommendation : B (There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.) TREATMENT The challenge for physicians and other clinicians is to diagnose, prevent, and treat osteoporosis before fractures occur. However, several studies have indicated that there has been a failure in the United States to apply preventive and treatment measures to many individuals at risk for bone disease [23]. For example, the use of BMD testing in this at-risk population has been estimated to be as low as 3%; calcium and vitamin D supplementation has been recommended to only 11% to 14% of this population; and antiresorptive therapy has been recommended for only 12% to 16% of this population [52; 53]. Additionally, Medicare cuts in reimbursement for DXA services (initiated in 2007) led to a decline in office-based provision of DXA services, a decline in retail prescriptions for osteoporosis therapies, and a decline in restarting drug therapy after an extended gap in treatment, despite a 2.6% increase in the U.S. population aged 65 years and older [54; 55; 56]. One retrospective analysis found a significant association between Medicare reimbursement reductions and decreased use of BMD testing in female Medicare beneficiaries who had no supplemental private health insurance [57].
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