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Should Thresholds for Bone Mineral Density Treatment Be Lowered?

Findings of two new studies suggest that a simple T-score threshold might be an inadequate approach to assessing risk for osteoporotic fractures.

Current World Health Organization guidelines suggest a bone-mineral density (BMD) threshold of 2.5 standard deviations below the mean for a young adult (i.e., T score, –2.5) to diagnose osteoporosis; it is unclear whether using this level as a treatment threshold will prevent most osteoporotic fractures. In a longitudinal observational study, sponsored by the manufacturer of an osteoporosis treatment, researchers examined fracture risk among 149,524 white women (mean age, 65). The women's peripheral (heel, forearm, or finger) BMD was measured using one of several types of absorptiometry or ultrasound equipment; they reported any new fractures at 12-month follow-up.

A total of 2259 fractures were reported, of which 18% were in women with T scores of –2.5 or worse (26% of hip fractures). Although fracture rate increased dramatically with decreasing T scores, only 45% of osteoporotic fractures occurred in patients who met the National Osteoporosis Foundation guidelines for pharmacologic treatment (T score, –2.0 or worse, or –1.5 or worse with clinical risk factors). In a companion study, the same authors present a decision algorithm that used prior fracture, a T score of –1.8 or worse, poor health status, and poor mobility to identify 74% of patients who subsequently experienced fractures.

Comment: Because this was not a controlled treatment trial, it would be inappropriate to make clinical recommendations based on the results. Nevertheless, the findings suggest that a simple T-score threshold could be an inadequate approach to risk assessment. However, a bigger problem is poor physician adherence to current screening and treatment recommendations, even for higher-risk patients.

— Thomas L. Schwenk, MD

Published in Journal Watch General Medicine June 18, 2004

Citation(s):

Siris ES et al. Bone mineral density thresholds for pharmacological intervention to prevent fractures. Arch Intern Med 2004 May 24; 164:1108-12.

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Miller PD et al. An approach to identifying osteopenic women at increased short-term risk of fracture. Arch Intern Med 2004 May 24; 164:1113-20.

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• Medline abstract (Free)