Screening to Prevent Osteoporotic Fractures

Importance: Osteoporotic fractures cause significant morbidity and mortality. Objective: To update the evidence on screening and treatment to prevent osteoporotic fractures for the US Preventive Services Task Force. Data Sources: PubMed, the Cochrane Library, EMBASE, and trial registries (November 1, 2009, through October 1, 2016) and surveillance of the literature (through March 23, 2018); bibliographies from articles. Study Selection: Adults 40 years and older; screening cohorts without prevalent low-trauma fractures or treatment cohorts with increased fracture risk; studies assessing screening, bone measurement tests or clinical risk assessments, pharmacologic treatment. Data Extraction and Synthesis: Dual, independent review of titles/abstracts and full-text articles; study quality rating; random-effects meta-analysis. Main Outcomes and Measures: Incident fractures and related morbidity and mortality, diagnostic and predictive accuracy, harms of screening or treatment. Results: One hundred sixty-eight fair- or good-quality articles were included. One randomized clinical trial (RCT) (n = 12 483) comparing screening with no screening reported fewer hip fractures (2.6% vs 3.5%; hazard ratio HR, 0.72 95% CI, 0.59-0.89) but no other statistically significant benefits or harms. The accuracy of bone measurement tests to identify osteoporosis varied (area under the curve AUC, 0.32-0.89). The pooled accuracy of clinical risk assessments for identifying osteoporosis ranged from AUC of 0.65 to 0.76 in women and from 0.76 to 0.80 in men; the accuracy for predicting fractures was similar. For women, bisphosphonates, parathyroid hormone, raloxifene, and denosumab were associated with a lower risk of vertebral fractures (9 trials n = 23 690; relative risks RRs from 0.32-0.64). Bisphosphonates (8 RCTs n = 16 438; pooled RR, 0.84 95% CI, 0.76-0.92) and denosumab (1 RCT n = 7868; RR, 0.80 95% CI, 0.67-0.95) were associated with a lower risk of nonvertebral fractures. Denosumab reduced the risk of hip fracture (1 RCT n = 7868; RR, 0.60 95% CI, 0.37-0.97), but bisphosphonates did not have a statistically significant association (3 RCTs n = 8988; pooled RR, 0.70 95% CI, 0.44-1.11). Evidence was limited for men: zoledronic acid reduced the risk of radiographic vertebral fractures (1 RCT n = 1199; RR, 0.33 95% CI, 0.16-0.70); no studies demonstrated reductions in clinical or hip fractures. Bisphosphonates were not consistently associated with reported harms other than deep vein thrombosis (raloxifene vs placebo; 3 RCTs n = 5839; RR, 2.14 95% CI, 0.99-4.66). Conclusions and Relevance: In women, screening to prevent osteoporotic fractures may reduce hip fractures, and treatment reduced the risk of vertebral and nonvertebral fractures; there was not consistent evidence of treatment harms. The accuracy of bone measurement tests or clinical risk assessments for identifying osteoporosis or predicting fractures varied from very poor to good.