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6 May 2008 | Volume 148 Issue 9 | Pages 685-701
Background: Screening for low bone mineral density (BMD) by dual-energy x-ray absorptiometry (DXA) is the primary way to identify asymptomatic men who might benefit from osteoporosis treatment. Identifying men at risk for low BMD and fracture can help clinicians determine which men should be tested.
Purpose: To identify which asymptomatic men should receive DXA BMD testing, this systematic review evaluates 1) risk factors for osteoporotic fracture in men that may be mediated through low BMD and 2) the performance of non-DXA tests in identifying men with low BMD.
Data Sources: Studies identified through the MEDLINE database (1990 to July 2007).
Study Selection: Articles that assessed risk factors for osteoporotic fracture in men or evaluated a non-DXA screening test against a gold standard of DXA.
Data Extraction: Researchers performed independent dual abstractions for each article, determined performance characteristics of screening tests, and assessed the quality of included articles.
Data Synthesis: A published meta-analysis of 167 studies evaluating risk factors for low BMD–related fracture in men and women found high-risk factors to be increased age (>70 years), low body weight (body mass index <20 to 25 kg/m2), weight loss (>10%), physical inactivity, prolonged corticosteroid use, and previous osteoporotic fracture. An additional 102 studies assessing 15 other proposed risk factors were reviewed; most had insufficient evidence in men to draw conclusions. Twenty diagnostic study articles were reviewed. At a T-score threshold of –1.0, calcaneal ultrasonography had a sensitivity of 75% and specificity of 66% for identifying DXA-determined osteoporosis (DXA T-score, –2.5). At a risk score threshold of –1, the Osteoporosis Self-Assessment Screening Tool had a sensitivity of 81% and specificity of 68% to identify DXA-determined osteoporosis.
Limitation: Data on other screening tests, including radiography, and bone geometry variables, were sparse.
Conclusion: Key risk factors for low BMD–mediated fracture include increased age, low body weight, weight loss, physical inactivity, prolonged corticosteroid use, previous osteoporotic fracture, and androgen deprivation therapy. Non-DXA tests either are too insensitive or have insufficient data to reach conclusions.
Author and Article Information
From Santa Clara Valley Medical Center, San Jose, California; Center for Primary Care and Outcomes Research, Stanford University, Stanford, California; Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California; RAND Corporation, Santa Monica, California; and Oregon Health & Science University, Portland, Oregon.
Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the U.S. Department of Veterans Affairs.
Acknowledgment: The authors gratefully acknowledge Smita Nayak, MD, for her expertise in osteoporosis screening tests and her assistance with our analysis.
Grant Support: This work was funded in part by the U.S. Department of Veterans Affairs Health Services Research and Development Evidence Synthesis Activity Pilot Program, Project ESP 05-226. Dr. Liu was supported by an Agency for Healthcare Research and Quality National Research Service Award (grant no. HS000028-19). Drs. Paige, Goldzweig, Wong, and Shekelle and Ms. Munjas were supported by the Veterans Affairs Administration. Ms. Zhou and Ms. Suttorp are employees of RAND Corporation. Dr. Orwoll is supported by National Institutes of Health funding (AR45647, AG027810, and RR024140).
Potential Financial Conflicts of Interest: Consultancies: E. Orwoll (Merck & Co., Eli Lilly, Servier). Honoraria: E. Orwoll (Merck & Co.). Grants received: E. Orwoll (Amgen, Pfizer, Eli Lilly, Novartis, Zelos Therapeutics, Imaging Therapeutics, Solvay Pharmaceuticals). Grants pending: H. Liu (Procter & Gamble).
Requests for Single Reprints: Hau Liu, MD, MBA, MPH, Santa Clara Valley Medical Center, 751 South Bascom Avenue, San Jose, CA 95128; e-mail, hauliu{at}stanford.edu.
Current Author Addresses: Dr. Liu: Santa Clara Valley Medical Center, 751 South Bascom Avenue, San Jose, CA 95128.
Drs. Paige, Goldzweig, Wong, and Shekelle and Ms. Munjas: Veterans Affairs Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, West Los Angeles, CA 90073.
Ms. Zhou and Ms. Suttorp: RAND Corporation, 1776 Main Street, Santa Monica, CA 90401.
Dr. Orwoll: Endocrinology, 3181 SW Sam Jackson Park Road, Portland, OR 97239. CLINICAL GUIDELINES
Screening for Osteoporosis in Men: A Systematic Review for an American College of Physicians Guideline
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