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ACP Guideline: Screening for Osteoporosis in Men
Osteoporosis is not just a women's health issue; rates among men are expected to increase 50% over the next 15 years.
Reviewed By Amir Qaseem, MD, PHD, MHA, FACP; Compiled By Conni Bergmann Koury, Editor-in-Chief
In 2008 the American College of Physicians (ACP) released a clinical practice guideline1 on screening for osteoporosis in men. Studies show that osteoporotic fractures result in substantial disease, death, and health costs in men.
In a news release from the ACP, Amir Qaseem, MD, PhD, MHA, FACP, senior medical associate in ACP's Clinical Programs and Quality of Care Department said: "Older men, especially those over the age of 65, need to be assessed regularly for risk factors for osteoporosis. Osteoporosis is not just a women's disease. It is significantly underdiagnosed and undertreated in men. Not enough older men are being screened."
The ACP guideline calls for physicians to periodically assess the risk factors for osteoporosis in older men. Clinicians should obtain a dual-energy X-ray absorptiometry (DXA) scan for men who are at increased risk for osteoporosis and are candidates for drug therapy. Further research to evaluate osteoporosis screening tests in men is also called for by the guideline.
Risk factors for osteoporosis in men are older age, low body weight, weight loss, physical inactivity, previous fractures not caused by substantial trauma, and ongoing use of drugs such as corticosteroids or those used to treat prostate cancer. According to the ACP, the prevalence of osteoporosis is estimated to be 7% in white men, 5% in black men, and 3% in Hispanic American men. Because of the aging population, however, the rates of osteoporosis in men are expected to increase nearly 50% in the next 15 years, and hip fracture rates are projected to double by 2040.
The guideline is based on a systematic evidence review of previously published studies;2 the following is an overview.
CLINICAL DIAGNOSIS OF OSTEOPOROSIS
There are two ways in which a diagnosis of osteoporosis is made: an occurrence of an osteoporotic fracture and the World Health Organization's bone density criteria, according to the guideline. WHO defines fragility fracture, an important characteristic of osteoporotic bone disease, as a fracture occurring from low-level trauma. WHO defines osteoporosis as a bone mineral density (BMD) >2.5 standard deviations (SDs) below that of a young healthy population as measured by DXA.
Although DXA is the standard for measuring BMD, it is not universally available, it is not portable, and is an imperfect predictor of future fracture. The ACP said that it is important to evaluate non-DXA tests that are sensitive, inexpensive, and easily implemented.
RISK FACTORS
The most important risk factors for osteoporosis in men are age (≥70 years), low body mass index (BMI) (BMI ≤20–25 kg/m2), weight loss (≥10% compared with usual adult weight), physical inactivity, use of oral corticosteroids, and previous fracture fragility. Other potential risk factors were reviewed, and it was revealed that androgen-deprivation therapy (pharmacologic and orchiectomy) is a strong predictor of osteoporosis and fracture, according to the guideline.
SCREENING METHODS
As mentioned, the diagnosis of osteoporosis is based on reduced BMD as measured by DXA. Because of the shortcomings discussed, however, the efficacy of other non-DXA screening tests was evaluated.
Calcaneal ultrasonography versus DXA. This diagnostic tool uses a probe that is placed on the heel to measure BMD. Its advantages include portability, low cost, and no ionizing radiation. There is no accepted threshold for a positive T-score, however, and they varied in the literature. A calcaneal ultrasonography T-score of –1.0 had a sensitivity of 75% and a specificity of 66% to diagnose BMD-determined osteoporosis (central DXA T-score ≤2.5). Using a calcaneal ultrasonography T-score of –1.5 resulted in a specificity increased to 78% but a sensitivity decreased to 47%.
Osteoporosis self-assessment screening tool (OST) versus DXA. According to the ACP, OST is a simple test that develops a risk score for osteoporosis by using a person's age and weight (risk score = [weight in kg — age in years] X 0.2). Again, there is no accepted threshold for a positive OST risk score. In two studies that evaluated Asian men, an OST risk score of –1 had a sensitivity of 70% to 90% and a specificity of 70% to diagnose BMD-determined osteoporosis. In a study of US veterans, an OST threshold of 3 was associated with a sensitivity of 93% and specificity of 66%. When the threshold was decreased to 1, the sensitivity fell to 75% and specificity rose to 80%.
Calcaneal ultrasonography versus fracture occurrence. Ten studies revealed that calcaneal ultrasonography moderately predicts fragility fractures in men. Several studies showed that each additional SD reduction in a calcaneal ultrasonography measurement resulted in an increased risk for hip fracture and nonspinal fracture.
Combination calcaneal ultrasonography and DXA. It has been suggested that calcaneal ultrasonography may be used to identify patients who should have a confirmatory DXA test. The evidence is less clear on the benefit of combining calcaneal ultrasonography and DXA BMD measurements compared with either test alone to predict fractures, according to the guideline.
RECOMMENDATIONS
(1) The ACP guideline recommends that clinicians periodically perform individualized assessment of risk factors for osteoporosis in older men (strong recommendation, moderate-quality evidence).
(2) ACP recommends that clinicians obtain DXA for men who are at increased risk for osteoporosis and are candidates for drug therapy (strong recommendation, moderate-quality evidence).
(3) ACP recommends further research to evaluate osteoporosis screening tests in men. "Although there is a large body of evidence about risk factors for osteoporosis in women, more research is needed to understand whether these risk factors also apply to men," according to the guideline. "Therapy should be evaluated in terms of fracture occurrence because of the significant disability, morbidity, mortality, and expenses that are associated with osteoporotic fractures." The ACP also suggested that the harms of screening, such as radiation exposure and false-positive results, should also be studied.
Amir Qaseem, MD, PhD, MHA, FACP, is with the American College of Physicians. He may be reached at aqaseem@acponline.org.
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