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Response

Adequacy of the guidelines is not the only issue.

Dr Sehmer correctly states that the 2002 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada likely need updating to reflect our current understanding of the evidence for and against screening and treatment, particularly in men. Recently meta-analyses have concluded that treatment of osteoporosis does reduce the risk of nonvertebral fractures, which has been demonstrated in a small number of trials for men, but the very low numbers of men studied limit the power to draw definitive conclusions about the efficacy of treatment—more research is therefore needed in this population.^1,2 As a result, several recent publications have concluded that screening high-risk men is probably both clinically effective and cost effective, but suggest that screening be initiated based on either an estimation of absolute 10-year fracture risk as determined by a risk calculator such as FRAX (an on-line tool developed at the University of Sheffield in the United Kingdom) or a combination of other high-risk indicators, such as weight loss, low physical activity, or more advanced age (somewhere in the range of 70 to 80 years).^3–6

As discussed in our article, there are many reasons that screening might not be carried out, with physician dissatisfaction with the quality of guidelines being an important factor. This study was a first step in describing the degree of application of this particular set of guidelines. Further studies on the reasons behind the results would be required to determine with certainty why so few men are screened, but informal feedback from colleagues suggests the guidelines themselves are not the only limiting factor. We also noted that screening rates were not substantially better for men older than 80 years of age, the group for which there is stronger evidence to support screening and treatment. We stand by our conclusion that improved screening strategies have the potential to reduce the rate of osteoporotic fractures in Canadian men.

References

1. MacLean C, Newberry S, Maglione M, McMahon M, Ranganath V, Suttorp M, et al. Systematic review: comparative effectiveness of treatments to prevent fractures in men and women with low bone density or osteoporosis. Ann Intern Med 2008;148(3):197–213. Epub 2007 Dec 17.[Abstract/Free Full Text]
2. Sawka AM, Papaioannou A, Adachi JD, Gafni A, Hanley DA, Thabane L. Does alendronate reduce the risk of fracture in men? A meta-analysis incorporating prior knowledge of anti-fracture efficacy in women. BMC Musculoskelet Disord 2005;6:39.[Medline]
3. Qaseem A, Snow V, Shekelle P, Hopkins R Jr, Forciea MA, Owens DK, et al. Screening for osteoporosis in men: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2008;148(9):680–4. Erratum in: Ann Intern Med 2008;148(11):888.[Abstract/Free Full Text]
4. Liu H, Paige NM, Goldzweig CL, Wong E, Zhou A, Suttorp MJ, et al. Screening for osteoporosis in men: a systematic review for an American College of Physicians guideline. Ann Intern Med 2008;148(9):685–701.[Abstract/Free Full Text]
5. Schousboe JT, Taylor BC, Fink HA, Kane RL, Cummings SR, Orwoll ES, et al. Cost-effectiveness of bone densitometry followed by treatment of osteoporosis in older men. JAMA 2007;298(6):629–37.[Abstract/Free Full Text]
6. Kanis JA, McCloskey EV, Johansson H, Strom O, Borgstrom F, Oden A, et al. Case finding for the management of osteoporosis with FRAX—assessment and intervention thresholds for the UK. Osteoporos Int 2008;19(10):1395–1408. Epub 2008 Aug 28.[Medline]

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