Panel
Suggests Osteoporosis Screening at Age 65 For Women
Critics
argue this is too little, too late
Starting
at age 65, women should be routinely screened for osteoporosis to reduce
the risk of bone fractures associated with the disease, says a panel
of experts in newly released recommendations.
And
women ages 60 to 64 at high risk for the disease should also be screened,
the panel says.
New
Guidelines Reiterate Previously Made
Recommendations
 The
new guidelines are the first made on osteoporosis by the US
Preventive Services Task Force, a panel sponsored by the federal
Agency for Healthcare Research and Quality. But they
mirror recommendations made in the past by such groups as the National
Osteoporosis Foundation and the American College of
Obstetricians and Gynecologists.
New
Recommendations Not Without Criticism
However,
the new guidelines, published in a recent edition of the Annals
of Internal Medicine, are already being criticized by some
osteoporosis experts who say screening at 65—or even 60—is
too little, too late. Screening should begin at least 10 years earlier,
the critics say.
Osteoporosis,
the "fragile bone" disease that results from low bone mineral density,
affects about 10 million Americans, including eight million women
and two million men, according to estimates from the National
Osteoporosis Foundation.
The
fractures that result, especially of the hip or spine, can cause costly
hospitalization and high convalescent costs. Another 34 million Americans
have low bone mass, putting them at higher risk of osteoporosis, says
the National Osteoporosis Foundation. Thinner women
are also at higher risk of developing the disease than heavier
women.
In
response to the criticism, those who assembled the new guidelines say
the recommendations are based on sound, scientific evidence.
"Fractures
in general occur later in life," says Dr. Heidi Nelson, associate professor
of medicine and medical informatics and outcome research at the Oregon
Health & Science University in Portland. She is the lead author
of the evidence review report used by the panel that also appears in the
same issue of the Annals of Internal Medicine.
"So
focusing on those who have the higher risk of fracture and treating
them" is considered the most effective strategy from a public health
viewpoint, she says. "These are evidence-based guidelines," she adds.
"By starting the screening at age 65, we have the biggest impact."
The
recommendation, the panel says, is based not on evidence that screening
can reduce fractures associated with osteoporosis but rather on evidence
that testing bone density can identify women who could benefit from
an array of bone-building medicines now available and perhaps avoid
fractures.
"As
a task force, we probably are looked upon as conservative," says Janet
Allan, the task force vice chair who is dean of the School of Nursing
at the University of Maryland in Baltimore.
"Our
charge is, we develop guidelines based on evidence," she adds. After
evaluating dozens of "high quality" studies, the panel found that the
benefit is to screen all women age 65 and older.
The
panel did not specify how frequently subsequent screenings should take
place after the initial screening.
How
Is Bone Mineral Density Measured?
To
test bone mineral density, a test called the DEXA (dual-energy x-ray
absorptiometry) is considered the gold standard. A person lies on an
examining table while the bones are scanned by an x-ray.
Even
though the new guidelines are based on scientific evidence, some experts
do not agree with them.
"I
think they're too late," says Dr. J. Michael Uszler, a nuclear medicine
physician at Santa Monica-UCLA Medical Center in Santa Monica, Calif.
"The prominent loss of bone density occurs in the first five years after
menopause," he says. In the United States, the average age of menopause
is about 51 years.
Ideally,
Uszler says, a woman should undergo a bone scan "within two years after
the end of menopause."
Another
critic of the new guidelines is Dr. Robert Heaney, professor of medicine
at Creighton University in Omaha, Neb., and a scientist at the university's
Osteoporosis Research Center.
"I
think they are too conservative, and driven by cost consideration,"
Heaney says. The cost of a DEXA scan is about $125 to $300, according
to Allan. But it can vary considerably.
At
Heaney's center, where 12,000 DEXA scans are done each year, the average
price per scan is just under $20, including personnel time and equipment
use, he says. Testing facilities could charge $40 and "still make a
profit," he adds.
"I
would recommend that women have access to bone scanning when they are
seriously interested in taking a look," Heaney says. For most, that
means midlife, from about age 40 to 60, he says.
As
Nelson acknowledges, "65 isn't magic. If women younger have a number
of risk factors," they should consider a test, too.
Adds
Allan, the task force vice chair: "There is always room for individual
preference."
Always
consult your physician for more information.
Online
Resources
Agency
for Healthcare Research and Quality
American
College of Obstetricians and Gynecologists
Annals
of Internal Medicine
National
Osteoporosis Foundation
US
Department of Health and Human Services
US
Food and Drug Administration (FDA)
US
Preventive Services Task Force
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October
2002
New
Guidelines Reiterate Previously Made Recommendations
New
Recommendations Not Without Criticism
How
Is Bone Mineral Density Measured?
New
Medication Promises to Revolutionize Treatment For Osteoporosis
Online
Resources
Find
a St. John's Mercy Physician
New
Medication Promises to Revolutionize Treatment For Osteoporosis
For
women who suffer from osteoporosis, the news is good: A new medication
promises to revolutionize treatment for the bone-thinning disease,
particularly in women with the most severe problems.
The
drug, a synthetic version of human parathyroid hormone called PTH,
works by helping the body build new bone—even after dramatic
loss has occurred.
"Unlike
other treatments for osteoporosis, which can help stop bone loss,
parathyroid hormone actually helps the body build new bone, so that
a woman has a chance to put back what her skeleton has lost over time
to osteoporosis," says endocrinologist Dr. Loren Wisner Greene, co-director
of the Bone Density Center at New York University Medical Center.
Although
most of us stop growing in height in our late teens, our skeleton
actually remains a work in progress for most of our lives, continually
breaking down and re-building bone mass at a fairly steady rate.
When
osteoporosis sets in, however, bone loss begins to occur faster than
the rebuilding process can take place. And that means instead of being
strong and solid, bones become porous, filled with little holes or
craters.
As
the disease progresses, there is less bone "mass" and more bone "holes"—turning
a strong skeleton into one that can be weak and vulnerable.
For
women, who comprise the vast majority of osteoporosis patients, the
problems generally become extremely apparent after menopause, a time
when levels of the hormone estrogen drop dramatically.
Why
is this important?
Estrogen
helps to regulate factors involved in bone formation, Wisner Greene
says. When estrogen levels fall, so does the production of new bone
cells, she adds.
For
women who start out with less bone mass to begin with, even a tiny
loss can spell trouble.
"The
end result can be weaker bones, and a dramatically increased risk
of fracture, particularly of the hip, spine, and wrist," says Wisner
Greene.
Although
there are a variety of medications available to treat osteoporosis,
they all work in pretty much the same way—to stop the bone loss.
PTH,
however, stimulates new bone cell production. The results, according
to endocrinologist Dr. John Adams, are nothing short of astounding.
"This
drug is remarkable in the fact that while all of the other [osteoporosis]
drugs are designed to inhibit bone loss, this is completely different
in that it stimulates the bone forming cell, the osteoblast," says
Adams, the director of the endocrinology, diabetes and metabolism
division at Cedars-Sinai Medical Center in Los Angeles.
When
combined with drugs that stop bone loss, like Fosamax (aldendronate),
parathyroid hormone becomes the ultimate way to increase skeletal
strength, Adams says.
"I'm
planning on putting every single one of my patients on this medicine
as soon as it becomes available. I feel that strongly about it," says
Adams.
As
good as it sounds, there are some caveats to consider. First, the
drug must be injected daily, which could be problematic for some women.
More
important, however, while human trials as long as 20 months showed
no serious side effects, a study involving rats found parathyroid
hormone has the potential for causing an extremely rare but life-threatening
form of bone cancer.
Although
the rats received doses far above the human equivalent and were treated
with the drug for an entire lifetime, the US Food and Drug
Administration (FDA) was concerned enough to request that
the manufacturer, Eli Lilly, conduct studies on larger animals using
dosages equal to that proposed for humans.
Those
results are expected soon and all indications are the drug will be
considered safe enough to get the FDA's nod of approval.
Until
then, Wisner Greene says another new treatment option is Evista (raloxifene),
a medication known as a SERM—short for "selective estrogen receptor
modulator."
Often
referred to as a "designer estrogen," SERMs work on a variety of diseases
"by offering the benefits of estrogen without the side effects of
estrogen replacement therapy, such as increased risk of breast and
uterine cancer," says Wisner Greene. In osteoporosis, Evista works
much like estrogen to help ensure that bone production is not outpaced
by bone loss.
Also
available are drugs known as bisphosphonates—medications such
as Fosamax, Didrocal (Etidronate) and Actonel (risedronate). They
work specifically to slow down bone loss. Although they can be hard
on the gastrointestinal tract, a new intravenous form is being tested,
with a one-time treatment offering protection for up to a year.
A
third alternative is the drug Miacalcin (calcitronin), a synthetic
version of a hormone made in the thyroid gland that is involved in
the breaking down of old bone cells. Available as a nasal spray, it
also works to reduce the rate of bone loss.
Finally,
for those who wish to take a more natural approach, boosting vitamin
D intake along with 1,500 mg of calcium daily is the way to go.
What
can also help: Weight-bearing exercises such as brisk walking, which
can increase the production of new bone.
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