Guidelines for the early detection of osteoporosis and prediction of fracture risk

Abstract

Objective. To assess methods available in clinical practice for the early detection of osteoporosis and prediction of fracture risk, and to set guidelines for their use. To make recommendations regarding cost-effective screening of asymptomatic subjects by physicians. Options. Three methods to predict fracture risk are considered: (i) clinical risk factor analysis; (ii) biochemical tests; and (iii) techniques to measure bone mass. Mass (unselected) screening is compared with screening only those at risk of sustaining a fracture. The optimal age/time of screening and therapeutic intervention thresholds are also considered. Outcomes. The main potential outcomes considered are the morbidity and mortality of advanced osteoporosis and fracture; the accuracy, precision, safety and costs of screening tests; and treatment for those at risk. Evidence. Based on the results of published recommendations of international osteoporosis societies, World Health Organisation guidelines and expert opinion. Values. The guidelines were developed by the National Osteoporosis Foundation in conjunction with other specialists and societies. A workshop attended by all the osteodensitometrists in the country was held in August 1994 to obtain consensus on recommendations. There were no major disputes about the content. The guidelines are intended to optimise heaJth care of society as a whole and are not geared to individual patients. Benefits, harms and costs. Up to 20% of victims of hip fracture die within 1 year and less than 50% ever regain the functional capability to lead an independent life. The cost of acute fracture care in the USA exceeded $10 billion in 1990. Early intervention has been shown to reduce the rate of vertebral and hip fractures by 50 - 70%. The cost of fracture care and of selected screening has not been measured in this country. Measurement of bone mass is safe, accurate and precise. Recommendations. (i) Measurement of bone mass employing dual-energy X-ray absorptiometry (DEXA) is at present the method of choice to predict hip and vertebral fracture risk. A single measurement can correctly identify the majority of those at risk. (ii) Densitometric screening of all (asymptomatic) women cannot be recommended, and selective screening according to specific indications is suggested. Densitometry is indicated at any age if the indication is valid. (iii) Guidelines for the interpretation of bone mass data, including therapeutic intervention thresholds, are suggested. Sponsors. The guidelines were developed and funded by the National Osteoporosis Foundation. Endorsement. Endorsed by the Medical Association of South Africa.

S Afr Med J 1996; 86: 1113-1116