Screening for osteoporosis

[Guest guest]

Hi All,

What do professionals say regarding how we should monitor for the

osteoporosis that

is a risk for those on CR?

See the pdf-available below.

Raisz LG.

Clinical practice. Screening for osteoporosis.

N Engl J Med. 2005 Jul 14;353(2):164-71. No abstract available.

PMID: 16014886

This Journal feature begins with a case vignette highlighting a

common clinical

problem. Evidence supporting various strategies is then presented,

followed by a

review of formal guidelines, when they exist. The article ends with

the author's

clinical recommendations.

.... Guidelines from Professional Societies

The U.S. Preventive Services Task Force (USPSTF), the National

Osteoporosis

Foundation (NOF), and the American Association of Clinical

Endocrinologists (AACE)

have recommended that all women should have a measurement of bone

mineral density at

the age of 65 years.52,53,54 This recommendation is based on the

sharp increase in

the incidence of fracture that occurs in association with low bone

mineral density

after the age of 65, as well as clinical trials showing a reduction

in the risk of

fracture when these women are treated. The USPSTF recommends that

women who are 60

to 65 years old and have multiple risk factors undergo bone-mineral-

density testing,

whereas NOF and AACE suggest that any postmenopausal woman with

multiple risk

factors should be tested; however, the guidelines do not specify how

risk factors

should be assessed or weighted. The International Society for

Clinical Densitometry

and AACE have provided additional guidelines for testing in men,

premenopausal

women, and children.41 These guidelines recommend bone-mineral-

density testing in

patients who have diseases or are receiving drugs that are likely to

cause secondary

osteoporosis (including glucocorticoids, antiepileptic drugs,

luteinizing

hormone–releasing hormone agonists, and aromatase inhibitors) and in

all patients

with fragility fractures.

Summary and Recommendations

Bone-mineral-density measurements should be obtained routinely in all

women over the

age of 65 years and in men and younger women who have had a fragility

fracture.

Compliance with this recommendation alone would be a great advance in

comparison

with current practice. As is outlined in Figure 2, all patients

should be asked

about risk factors and secondary causes of osteoporosis and should be

advised about

the recommended intake of calcium and vitamin D (1200 mg and 400 to

800 IU daily,

respectively, for postmenopausal women), weight-bearing physical

activity, and the

dangers of smoking. The decision to measure bone mineral density in

postmenopausal

women under the age of 65 should be made on the basis of the presence

of risk

factors that increase the likelihood of detecting osteoporosis or

osteopenia. For

example, in the patient described in the vignette, obtaining a dual-

energy x-ray

absorptiometric scan would be justified on the basis of the patient's

family history

of fracture, her low weight, and the likelihood that a finding of low

bone mineral

density would influence her treatment.

Figure 2. Flow Chart for Recommendations Regarding Selection of

Patients for

Dual-Energy X-Ray Absorptiometry (DXA).

For peripheral densitometry, each system will have different levels

of T-score

cutoff. In most cases, dual-energy x-ray absorptiometry will be

recommended for

patients with T scores of –1.0 or lower. It is important to identify

diseases or

drugs that are likely to cause skeletal fragility or to increase the

risk of falls.

Risk factors that routinely warrant bone-mineral-density testing

include an age of

more than 65 years, a personal history of fracture (particularly

fragility fracture)

or height loss of more than 2 cm, a family history of fracture in a

first-degree

relative, low body weight (less than 126 lb), and recent weight loss

(more than 5

percent). Other risk factors include female sex, late menarche, early

menopause, low

calcium intake, vitamin D insufficiency, smoking, excess alcohol

intake, physical

inactivity and muscle weakness, and impaired vision or balance.

Secondary causes of

osteoporosis include hyperparathyroidism, hyperthyroidism, Cushing's

syndrome,

glucocorticoid therapy, inflammatory disorders (including arthritis,

bowel disease,

and pulmonary disease), hypogonadism (including treatment with

luteinizing

hormone–releasing hormone agonists and aromatase inhibitors), cancer

(especially

hematologic conditions), congenital disorders (including osteogenesis

imperfecta and

homocystinuria), and neurologic disorders (including immobilization

and treatment

with antiepileptic drugs). BMD denotes bone mineral density.

Although data to guide the frequency of rescreening are lacking, it

would be

appropriate to repeat bone mineral density measurement in two years

in patients with

osteopenia and in three to five years in patients with normal bone

density. Many of

these patients will not lose bone if they have an adequate intake of

calcium and

vitamin D and exercise regularly. Risk factors should be reassessed

and lifestyle

advice reinforced at every visit with the patient. This approach is

consistent with

the recent Surgeon General's Report on Bone Health and Osteoporosis

(www.surgeongeneral.gov).

Dr. Raisz reports having received honoraria from Novartis, Bayer, and

Procter &

Gamble and grant funding from Servier.

Al Pater, PhD; email: