A direct comparison of the recommendations presented in the above guidelines for screening and risk assessment for osteoporosis is provided in the tables below.
Areas of Agreement
Risk Assessment
ACPM, NAMS, and UMHS recommend assessing patients for risk factors associated with osteoporosis and osteoporotic fracture. As the target populations of the guidelines differ, so too do the recommendations regarding who should be assessed: all adult patients ≥age 50 (ACPM); all postmenopausal women (NAMS); all adults (UMHS). As the focus of the USPSTF guideline is screening, the Task Force does not provide any explicit recommendations on risk assessment. It does, however, address it in the context of determining eligibility for screening.
All of the guidelines agree that the key components of a risk assessment are assessing the individual for both clinical risk factors (e.g., age, tobacco smoking, history of fragility fracture, low body weight) and secondary risk factors (e.g., glucocorticoid therapy, rheumatoid arthritis, other secondary causes of osteoporosis), determining an absolute fracture risk, and subsequent BMD testing (if indicated) based on risk profile. All four groups address the use of osteoporosis risk assessment tools and all cite the WHO's FRAX® as an example of a well-validated and reliable risk assessment calculator. In addition to assessment of risk factors, NAMS also recommends a physical examination that includes an annual measurement of height and weight, along with an assessment for chronic back pain and kyphosis.
Measurement of BMD: Modality and Frequency
The guidelines agree that DXA is the preferred and most widely accepted technique for measurement of BMD. All of the groups acknowledge, however, that certain factors can interfere with the accuracy of DXA measurements. ACPM and UMHS cite vertebral compression fractures, osteoarthritis, osteophytes, and vascular calcification as factors that may spuriously elevate BMD measurement by DXA.
With regard to screening tools other than DXA, ACPM, UMHS, and USPSTF also address calcaneal QUS. While the groups agree that benefits compared to DXA include being portable, not exposing patients to radiation, and being less expensive, none recommends its routine use. According to ACPM, given the poor sensitivity of QUS for detecting osteoporosis, it has limited application in evidence-based screening programs. A limitation cited by USPSTF is that while calcaneal QUS predicts fractures of the femoral neck, hip, and spine as effectively as DXA, current diagnostic and treatment criteria for osteoporosis rely on DXA measurements only, and criteria based on QUS or a combination of QUS and DXA have not been defined.
ACPM also addresses QCT, which they conclude has not yet been extensively researched or validated in relation to T-scores that predict fracture risk.
ACPM, NAMS, and UMHS also address biochemical markers of bone formation and resorption. There is overall agreement that they do not predict BMD or reliably estimate fracture risk, and that their routine use in clinical practice is not recommended. The groups agree that these markers are most often used in research settings to monitor response to antiresorption therapy, owing to their potential to demonstrate changes in bone remodeling earlier (within several days to months) than BMD changes, which can require 1 to 3 years.
In terms of when to repeat BMD testing, there is overall agreement that an interval of at least two years is appropriate for most people. UMHS provides repeat testing recommendations based on the T-score from the patient's first DXA and the level of clinical risk, with repeat testing intervals ranging from 6 to 12 months (in the case of glucocorticoid use and/or transplantation) to 3 to 5 years.
Areas of Difference
Screening in Women
The groups agree that the decision to test BMD should be based on a woman's clinical risk factors/risk profile, as well as the potential impact of results on management. All four groups recommend BMD testing for all women aged 65 years or older, regardless of clinical risk factors. ACPM and NAMS also recommend BMD testing for postmenopausal women younger than 65 with osteoporotic risk factors. The UMHS and USPSTF guidance differs from that of ACPM and NAMS, in that these two groups recommend screening women younger than 65 (USPSTF specifies 50 to 64), regardless of menopausal status, using a 10-year fracture risk threshold of 9.3% according to the FRAX tool. A 9.3% 10-year risk is the equivalent to that of a healthy 65 year-old woman (USPSTF specifies a 65-year-old white woman with no other risk factors). USPSTF recommends that clinicians consider each patient's values and preferences and use clinical judgment when discussing screening with women in this age group. They note that menopausal status is one factor that may affect a decision about screening in this age group.
Screening in Men
ACPM endorses recommendations made by the National Osteoporosis Foundation to screen all men aged ≥70. They also recommend screening in men aged 50-69 if at least one major or two minor risk factors for osteoporosis are present. UMHS similarly considers men >70 years, as well as men <70 years with at least one osteoporotic risk factor, to be at high risk and therefore indicated for screening. USPSTF, in contrast to ACPM and UMHS, concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men. They discuss factors that clinicians should consider when deciding whether to screen men for osteoporosis.
