Making DEXA count to avoid unneeded retesting

We know that osteoporosis and osteopenia have a clinically impactful effect on our morbidity, mortality, and costs, and this is why we emphasize screening. The U.S. Preventive Services Task Force has clear guidelines of when to start screening for osteoporosis, which were last published in 2018 and are currently being updated. However, we do not have clear guidelines on when to repeat testing after the initial bone density exam. The U.S. Preventive Services Task Force states to repeat at an interval no more frequently than every two years. Many clinicians only order bone density testing when it will change their management, in an effort to provide more high-value care and lessen the cost to the health care system and burden on patients.

From available evidence, I've looked into what intervals would be most impactful to rescreen my patients. The initial bone density and hip fracture risk score can give you some clear guidelines on when to repeat your screenings. We have one study, a prospective study of about 5,000 patients by the Study of Osteoporotic Fractures Research Group, that was published Jan. 19, 2012, by the New England Journal of Medicine, and that's the largest body of data we have to clarify when to rescreen. Among most of the patients who had a normal bone density and were followed for 15 years, less than 10% became osteoporotic, and within three to eight years, many of those patients did develop moderate- or low-risk osteopenia. Very few developed clinically relevant osteoporosis, less than 10%.

What has become best practice at this time, with the evidence available, is if patients have osteoporosis on an initial bone density result, repeat the dual-energy X-ray absorptiometry (DEXA) again in two years or at any interval that might change your management. If the patient is on pharmacological management with a bisphosphonate, you might consider repeating your bone density [screening] in four to five years, because that's really when you might change your clinical management of that patient, either changing or considering a different treatment or considering a drug holiday. If on the initial bone density [screening] your patient has osteopenia with a low risk of fracture, and if there are no other additional new risk factors that develop, you could safely consider repeating the bone density test again in about five years. If your patient has a moderate or high fracture risk with osteopenia, consider repeating your bone density [screening] again in about three years, assuming no other risk factors change. And if your patient's bone density on that initial bone density test is normal, you're really not likely to benefit from repeating the exam for five to 10 years, unless they have a new significant osteoporosis-related risk factor.

Doing bone density tests every two years off the bat puts stress on patients, puts costs on patients, and [adds] cost and burden to our health care system for an unnecessary test that may not be the highest priority, especially if [patients] have low risk with normal [results] or osteopenia on their bone densities. For patients who are at a high risk of fracture, have osteoporosis, or are on drugs that greatly increase their risk of osteoporosis or other clinical changes, you should be repeating screening more frequently, every two to three years especially if it will change your management, and if [they have] osteopenia with a low risk of fracture, consider repeating your screening in three to five years.

All postmenopausal women should be warned about prevention of osteoporosis and consider conservative management if they're at risk. If there's osteopenia, then we usually recommend conservative management to ensure that they are receiving a sufficient amount of vitamin D and calcium, either in their diet or supplemental, and regular exercise for prevention and conservative treatment of osteopenia. If they have osteoporosis or a high risk of fracture, then we recommend that conservative treatment, as well as offering pharmacological treatments to reduce their risk of hip fracture or any fracture in the next 10 years.

The patients I counsel on this issue in my practice tend to fall into two different subsets. I have some patients who routinely, every two years, choose to get their bone density tested, even though they may not necessarily need it. They haven't had a significant drop in their bone density, or they had a normal bone density at baseline. And those patients, I really encourage them to focus their medical efforts on prevention, on their other health concerns and health conditions. Then I have patients who are at a very high risk of fracture and may be on medical treatments like aromatase inhibitors for breast cancer, for instance, and I want them to get in and get a bone density test more frequently, but because so many patients are being scheduled, or because of the burden of cost or ability to get to the screening center, sometimes that gets delayed.

Given all this, I really want us to consider, as clinicians, making our bone density testing impactful, where we know that it might result in a change in management, rather than creating more cost to the health care system or burden to the patient by doing the test if it's not going to likely change our management.