Indications of DXA in Women Younger Than 65 yr and Men Younger Than 70 yr: The 2013 Official Positions

doi:10.1016/j.jocd.2013.08.002

Journal of Clinical Densitometry

Volume 16, Issue 4, October–December 2013, Pages 467-471

https://doi.org/10.1016/j.jocd.2013.08.002 Get rights and content

Abstract

Dual-energy X-ray absorptiometry (DXA) is the method of choice to assess fracture risk for women 65 yr and older and men 70 yr and older. The 2007 International Society for Clinical Densitometry Official Positions had developed guidelines for assessing bone density in younger women during and after the menopausal transition and in men 50–69 yr and the 2008 National Osteoporosis Foundation (NOF) guidelines recommended testing in postmenopausal women younger than 65 yr and men 50–69 yr only in the presence of clinical risk factors. The purpose of the 2013 DXA Task Force was to reassess the NOF guidelines for ordering DXA in postmenopausal women younger than 65 yr and men 50–69 yr. The Task Force reviewed the literature published since the 2007 Position Development Conference and 2008 NOF, reviewing clinical decision rules such as the Osteoporosis Screening Tool and FRAX and sought to keep recommendations simple to remember and implement. Based on this assessment, the NOF guidelines were endorsed; DXA was recommended in those postmenopausal women younger than 65 yr and men 50–69 yr only in the presence of clinical risk factors for low bone mass, such as low body weight, prior fracture, high-risk medication use, or a disease or condition associated with bone loss.

Introduction

The risk for low bone mass and osteoporotic fracture is increased among women 65 yr and older and in men 70 yr and older, so that screening bone density in these patients has been generally supported 1, 2. The previous Position Development Conference in 2007 had recommended bone density testing in men younger than 70 yr and in perimenopausal women only if they have clinical risk factors such as low body weight, prior fracture, or high-risk medication use, in an effort to identify younger patients at high risk for low bone mass and osteoporotic fracture (3). The National Osteoporosis Foundation guidelines, in 2008 and then reaffirmed in 2013, recommended bone density testing in postmenopausal women and men aged 50–69 yr based on risk factor profile (1). At the 2013 Position Development Conference, the dual-energy X-ray absorptiometry (DXA) Task Force was asked to review the NOF guidelines regarding bone density testing in postmenopausal women younger than 65 yr and men 50–69 yr. This article will describe the methodology of the Task Force, questions posed to the Task Force, the Statement addressing those questions that were voted as appropriate without disagreement by the 2013 International Society for Clinical Densitometry (ISCD) Position Development Conference (PDC) Expert Panel and approved by ISCD Board of Directors, and explain the rationale behind the statement.

Section snippets

Methodology

The methods used to develop and grade the Official Position Statement for DXA presented in this document are presented in the Executive Summary of the 2013 PDC regarding bone densitometry that is also in this issue. In brief, the Position Statement presented here was rated as appropriate without disagreement by the Expert Panel of the 2013 ISCD PDC. This position was also rated by the Expert Panel on quality of evidence, strength of recommendation, and applicability. Quality of evidence is

Questions for Future Research

Current guidelines about the cost-effectiveness of screening for osteoporosis and treating it are based on certain assumptions about the cost of the DXA and treatment. Because the cost of treatment and reimbursement for DXA have fallen over the past few years, the question is whether cost-benefit analyses based on the new costs will justify moving thresholds for screening and intervention to an earlier age.

Current guidelines suggest treating patients with osteoporosis, or those with osteopenia

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Positions of The International Society for Clinical Densitometry and Their Etiology: A Scoping Review
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The International Society for Clinical Densitometry convenes a Position Development Conference (PDC) every 2 to 3 years to make recommendations for guidelines and standards in the field of musculoskeletal measurement and assessment. The recommendations pertain to clinically relevant issues regarding the acquisition, quality control, interpretation, and reporting of measures of various aspects of musculoskeletal health. These PDCs have been meeting since 2002 and have generated 214 Adult, 26 FRAX, 41 pediatric, and 9 general nomenclature consideration positions, for a total of 290 positions. All positions are justified by detailed documents that present the background and rationale for each position. However, the linkage to these publications is not maintained by the ISCD or any other publication such that physicians cannot easily understand the etiology of the positions. Further, the wording of many positions has changed over the years after being reviewed by subsequent PDCs. This scoping review captures the references, changes, and timeline associated with each position through the 2019 PDC. It is meant to serve as a guide to clinicians and researchers for intelligent use and application of the positions.
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To determine bone mineral density (BMD) z scores in adults with cerebral palsy (CP), an understudied population.
Cross-sectional.
Medical facility.
Adults (N=48; mean age, 34.3±5.8y; range, 25–46y) with CP.
Not applicable.
BMD z scores at the lumbar spine and hip using dual-energy x-ray absorptiometry, Gross Motor Function Classification System (GMFCS), body mass index (BMI), and ambulatory status.
Mean BMD z scores were −1.40 for the lumbar spine, −1.36 for the total hip, and −1.02 for the femoral neck. The z scores were significantly lower for the nonambulatory group at all 3 sites (P<.05). Significant differences were found among GMFCS levels for the lumbar spine and total hip z scores (P<.05). For the lumbar spine, the mean z scores for level V (the lowest mobility level) were significantly lower than the mean for levels I/II (P=.001), III (P=.002), and IV (P=.013). For the total hip, the mean z scores for level V were significantly lower than the mean for levels I/II (P=.045). A significant positive relationship between the z scores and age was found for the lumbar spine (Spearman ρ=.40, P=.005). Significant positive relationships between BMI and z scores were found for all sites (P<.05).
This study contributes to the sparse literature about bone health in adults with CP. In contrast with pediatric data, z scores did not decrease as a function of age in this adult cohort. This information is important for clinicians considering treatment options for this population.
Evaluating and mitigating fracture risk in established rheumatoid arthritis
2015, Best Practice and Research: Clinical Rheumatology
Citation Excerpt :
ISCD and National Osteoporosis Foundation (NOF) recommend BMD assessment for all women aged 65 and older and all men aged 70 and older. Both groups also recommend BMD testing in postmenopausal women and men aged 50–69 with risk factors for osteoporosis, defined as low body weight, prior fracture, high-risk medication use, and diseases associated with bone loss [7,14]. In slight contrast, the United States Preventive Task Force (USPTF) recommends BMD assessment in women under age 65 based on FRAX assessment, with BMD testing recommended for patients whose 10-year risk of major osteoporotic fracture is greater than that of a 65-year-old white woman without other risk factors (9.3%).
Patients with rheumatoid arthritis are predisposed to systemic bone loss, and they are at an increased risk of fractures. Although there are similarities in the patient demographics between rheumatoid arthritis patients and the general population of osteoporosis patients, there are factors, particularly the use of glucocorticoids, which are specific to rheumatoid arthritis. These factors can lead to an increased risk of bone loss and fracture. Given that fractures are often very debilitating, especially in elderly patients, it is of paramount importance for the practicing rheumatologist to be aware of ways to reduce the risk of fracture in patients with rheumatoid arthritis. This review discusses currently available modalities for fracture risk assessment as well as pharmacologic and lifestyle interventions available to treat and prevent bone loss in rheumatoid arthritis patients.
Use of FRAX as a Determinant for Risk-Based Osteoporosis Screening May Decrease Unnecessary Testing While Improving the Odds of Identifying Treatment Candidates
2014, Women's Health Issues
Citation Excerpt :
USPSTF screening by FRAX threshold would not be appropriate for those with a fracture history or secondary causes, because either should trigger screening regardless of their FRAX score. In this regard, our findings are consistent with the position statement of the International Society for Clinical Densitometry 2013 DXA Task Force regarding indications for BMA in women younger than 65, but the devil is in the details of how the specific risk factor for low bone mass of “disease or condition associated with bone loss” is defined and identified (Malabanan et al., 2013) Application of the USPSTF criteria would have potentially restricted testing for many of our younger women.
We have assessed the hypothetical impact of guideline-concordant osteoporosis screening on baseline behaviors utilizing two different guidelines and determined the relative ability of each to identify osteoporosis treatment candidates.
We conducted secondary analyses from the Fracture Risk Perception Study, which enrolled patients aged 50 to 75 years to complete questionnaires about their bone health. We determined our baseline screening rates and detection of treatment candidates and then assessed the hypothetical impact of adherence to U.S. Preventive Services Task Force (USPSTF) and National Osteoporosis Foundation (NOF) criteria, particularly for women aged 50 to 64.
Of 144 women aged 50 to 64 years screened, 14 (9.7%) were treatment candidates. Screening based on identification of one or more risks (NOF) would lead to testing of 102 of the 144 patients (71%) to identify 12 of 14 treatment candidates (86%). Applying USPSTF criteria (9.3% FRAX threshold) would test 45 of the same 144 women (31%) to identify 11 of 14 treatment candidates (79%). NOF risk-based criteria would result in a moderate absolute screening rate reduction (16%, p = .0011; 95% CI, 7%–25%), but only marginal improvement in identifying treatment candidates (odds ratio, 2.67; 95% CI, 0.57–12.47). Applying the more selective USPSTF criteria greatly reduced unnecessary testing (56% absolute screening rate reduction; p < .0001; 95% CI, 47%–64%) while further improving the odds of identifying treatment candidates (odds ratio, 10.35; 95% CI, 2.72–39.35).
When contemplating screening younger patients, systematic calculation of FRAX and ordering only when the 9.3% fracture risk threshold is reached may decrease unnecessary screening for many women while still identifying appropriate osteoporosis treatment candidates.
High Prevalence of Osteoporosis and Morphometric Vertebral Fractures in Indian Males Aged 60 Years and Above: Should Age for Screening Be Lowered?
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Citation Excerpt :
There is a wide variation in the prevalence of osteoporosis, hip fracture, and VF among various ethnic groups. Screening guidelines by several societies such as the International Society for Clinical Densitometry (6), the International Osteoporosis Foundation (7), and the Endocrine Society (8) recommend screening for osteoporosis in otherwise healthy males aged 70 years and above. Osteoporosis Canada recommends screening for osteoporosis in otherwise healthy males aged 65 years and above (9).
Current guidelines recommend bone mineral density (BMD) measurement in asymptomatic men above age 70 years and vertebral fracture (VF) assessment above 80 years with T-score <−1.0 with risk factors. We studied the prevalence of osteoporosis and morphometric VF in asymptomatic males aged 60 years and above in North India. Free-living community-dwelling men (n = 241, age: mean ± standard deviation 68.0 ± 6.2 years) underwent a detailed history, physical examination, biochemical evaluation, and BMD measurements at 3 sites: lumbar spine, total hip (TH), and femoral neck (FN). Morphometric VF were assessed by instant vertebral assessment using Genant et al's semiquantitative method. We observed osteoporosis, osteopenia, and normal BMD in 19%, 56%, and 25% of subjects, respectively. The decade wise prevalence of osteoporosis in the age groups 60–70 years, 71–80 years, and >80 years was 16.9%, 17%, and 50%, respectively. Mean serum 25OHD levels were 17.2 ± 10.3 ng/mL. Vitamin D deficiency (<20 ng/mL) and secondary hyperparathyroidism (plasma intact parathyroid hormone >65 ng/mL) were present in 68.8% and 45.4%, respectively. VF were present in 29.6% subjects (grade I: 58%, grade II: 32.4%, and grade III: 8.8%). Age and iPTH had significant negative correlation with BMD at FN and TH. Serum 25OHD had no correlation with BMD at any site. The prevalence of VF was positively associated with age (p = 0.018) and negatively associated with BMD at FN (p = 0.002) and TH (p = 0.013). Osteoporosis and VF are common in asymptomatic Indian males aged 60 years and above. Screening for osteoporosis and instant vertebral assessment may be recommended earlier than currently existing guidelines.
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2013 Position Development Conference on Bone DensitometryIndications of DXA in Women Younger Than 65 yr and Men Younger Than 70 yr: The 2013 Official Positions

Abstract

Introduction

Section snippets

Methodology

Questions for Future Research

J Clin Densitom

Bone

Mayo Clin Proc

Clinician's Guide to Prevention and Treatment of Osteoporosis

Screening for osteoporosis: U.S. preventive services task force recommendation statement

Ann Intern Med

Evaluation of decision rules for referring women for bone densitometry by dual-energy X-ray absorptiometry

JAMA

Use of clinical prediction rules in detecting osteoporosis in a population-based sample of postmenopausal women

Arch Intern Med

Effects of lifestyle and risk factors on bone mineral density in a cohort of italian women: suggestion for a new decision rule

Calcif Tissue Int

More bone density testing is needed, not less

J Bone Miner Res

Fracture risk assessment without bone density measurement in routine clinical practice

Osteoporos Int

Selection of women aged 50-64Yr for bone density measurement

J Clin Densitom

2013 Position Development Conference on Bone Densitometry
Indications of DXA in Women Younger Than 65 yr and Men Younger Than 70 yr: The 2013 Official Positions