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Thursday, January 19, 2012

STUDY CALLS FOR REDUCED USED OF BONE MINERAL DENSITY TESTING

THE VIEW FROM THE OFFICE


STUDY CALLS FOR REDUCED BONE MINERAL DENSITY TESTING FOR OSTEOPOROSIS

     It is a long-standing problem that there has been little or no hard evidence to guide the decision on how to screen for and prevent osteoporosis. The United States Preventive Services Task Force has gone ahead and endorsed it despite the lack of evidence. The recent "Welcome to Medicare" guidelines will pay for it every 2 years. I have long been opposed to this test because it is expensive and because no one is sure how to use it. The vast majority of its value lies in the first screening with a bone density test technique, and, simply stated, none of the numerous experts has any real idea of if and when to repeat the test for patients who are normal, for patients who have osteopenia, and/or for patients who have actual osteoporosis.  My recommendation has been for everyone simply to exercise regularly and take the recommended amount of daily calcium (1000 mg/day) and vitamin D (800 IU/day).
     Until now, that is. A study just published today in the New England Journal of Medicine (Gourlay ML et al. NEJM 2012; 366: 225-33) answered the question. They studied a group of 4957 women, 67 years of age or older, who had normal initial bone density or had only mild osteopenia on initial testing; these women had no history of fracture of the wrist, hip, or spine and were not taking medications like Fosamax for osteoporosis. They analyzed their bone density at 2 years, 6 years, 8 years, 10 years, and 16 years. They divided their subjects into 3 subgroups:  a group with normal bone density and a group with osteopenia (mild, moderate, and severe) and analyzed the time until progression to frank osteoporosis. 
     The estimated time for women with normal bone density to progress to osteoporosis was 16.8 years. The estimated time for women with mild osteopenia to progress to osteoporosis was 17.3 years, for women with moderate osteopenia, 4.7 years; and for women with severe osteopenia, 1.1 years.
     The investigators conclude that the appropriate re-screening interval in which to repeat any type of bone density testing was 15 years for either normal women or women with mild osteopenia. For women with moderate osteopenia, rescreening should take place in 5 years, and for women with advanced osteopenia, rescreening should take place every years.
     This recommendation is clear and firmly evidence-based. A majority of the currently carried out rescreening with bone density tests, usually on an annual or biannual basis, should cease. Live a healthy lifestyle, exercise, take your calcium and vitamin D, and say your prayers--"Lord, may I live another 15 years."  Then you can get your repeat bone density test and derive some benefit from it. The rest is waste for women with normal bone density or only mild osteopenia.





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