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Osteoporosis screening in older women: fewer hip fractures but no overall reduction in fractures
Clinical Question
Does screening older women for osteoporosis using the Fracture Risk Assessment tool decrease fractures?
Bottom line
In this study, inviting women 70 to 85 years of age to be screened for osteoporosis using the Fracture Risk Assessment (FRAX) tool did not reduce the overall rate of fractures or clinical fractures. The screened group had a small reduction in the rate of hip fractures, however, and hip fractures are the most devastating. 1b-
Reference
Study design: Randomized controlled trial (nonblinded)
Funding: Government
Setting: Outpatient (primary care)
Synopsis
These authors randomized women 70 to 85 years of age recruited from primary care practices in the United Kingdom to receive a baseline screening using the FRAX (n = 6233) or to usual care (n = 6250). They excluded women already being treated for osteoporosis and patients with dementia, terminal illness, recent bereavement, or any other circumstance making them "unsuitable to enter a research study." Each participant completed an online version of the FRAX at baseline after which the randomization occurred. The women randomized to receive screening had their FRAX data converted into an age-adjusted 10-year fracture risk score, which was then used to determine whether to offer dual-energy X-ray absorptiometry (DEXA) scanning to assess bone mineral density. The researchers re-estimated the 10-year fracture probability among those undergoing subsequent DEXA scans and classified the women as being at low risk or high risk of fracture and provided this information to the patient and her physician. The researchers assessed the women serially for up to 5 years after enrollment to see if any had experienced a fracture, which they then verified by reviewing records and imaging reports. At the end of 5 years, omore than 1000 women had died, nearly 600 declined to provide follow-up data, and another 150 were unreachable—overall 15% of enrolled women were not available at the end of the study. Nearly half the women in the screening group were initially classified as being at high risk of fracture and invited to have a DEXA scan; 8% either declined to have the scan or declined to share the results. Only 14% of those initially screened were still at high risk of fracture once the DEXA scans were incorporated into their revised risk score. At the end of the first year, 15% of screened women had been given an osteoporotic medication compared with only 4% of the control women. Over the subsequent years of follow-up, the proportion of screened women who were taking drugs remained stable while the proportion of control women gradually increased to 10% by study's end. By the end of the study, there was no significant difference in the rate of women who had at least 1 osteoporosis-related fracture (13%) or clinical fracture (15%). There was also no significant difference in the number of women who died (8%), had a decreased quality-of-life score, or had any anxiety related to osteoporosis. Screened women, however, were less likely to have a hip fracture (2.6%) than control women (3.5%; number needed to treat = 117; 95% CI 69 - 396). The authors don't report on the harms of downstream treatment.
Reviewer
Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI
Comments
Vertebral body fracture due to osteoporosis on x-ray is more common and in some part less symptomatic , or become asymptomatic without intervention , but hip fx is different hx so this study shows decrease in hip fx so the testing and treatment is effective.
?what is elderly is very vague should not be used
we need to develop a score in relation to age range frailty of physical condition.
Why is it we never hear about the most obvious studies?
Simply take all the women who lift weights and compare them to all the women who don’t.
Of course, radiologist and drug companies will not make any money if this shows a positive result. Hence, it will never happen
Good poem
Lots of my patients taking medicine for Osteoporosis
Some of them are on prolia doing well
Confirms that age alone is the major risk factor and further screening is only useful if it will help convince the patient to take osteoporosis meds.
Did the red-haired subjects have more fractures?
Unfortunately, a RCT like this does not tell the whole story. We need to look closely at those that had fractures and figure out what were the slight differences in their genetic makeup, as expressed in general body traits, types of past illness, personality, food likes and dislikes, perspiration, body thermals, etc. We can't wait for genetic testing to catch up -- we need to look at the manifestations of genes, in order to find the sub-groups that might benefit from a sometimes costly, potentially risky drug. It's all out there already, hiding in plain view. Large pooling of subjects just doesn't cut it anymore. If we start individualizing , then we might identify those patients we can influence with treatment and change the most important outcome - quality of life in the elderly.
confirms that we don't have a good understanding of osteoporosis nor do we have good treatment . Huge numbers with incomplete data