Choosing Wisely on Getting a Bone Density Test

Article taken from pages 10-11 of the July/August Newsletter 2014

By Charlea T. Massion, MD &Adriane Fugh-Berman, MD

Recommendations about bone density (BD) testing have shifted over the last few years — we are proud to say, more toward what the NWHN has recommended for over a decade! This article reviews the BD testing recommendations from the Choosing Wisely® (CW) campaign. This campaign grew from an American Board of Internal Medicine program called “More is Less,” which emphasized the under-reported risks of many medical tests and treatments.  CW’s website describes its purpose as being to “spark conversations between providers and patients to ensure the right care is delivered at the right time.”

The website includes lists created by participating organizations of Things Providers and Patients Should Question. “These lists represent specific, evidence-based recommendations providers and patients should discuss together in order to make wise decisions about the most appropriate care based on their individual situation.”ii

Below, in italics, are the CW guidelines for “Bone Density Testing: When You Need It and When You Don’t,” followed by our comments and interpretations.

For a woman, it can be worthwhile to get an initial bone density test, but NOT before age 65.

Here’s why: For decades, many physicians ordered bone density (BD) tests for women in their 40s on the premise of getting a BD “baseline” before menopause. (Some uninformed doctors probably still do this!) This test is worthless! There is essentially no correlation between a pre-menopausal woman’s BD and her actual risk of hip or other osteoporotic fractures in her 70s and 80s. These too-early “baseline” screening tests led to legions of young women being diagnosed with “osteopenia,” which is a just a number and not an actual bone disease. To treat osteopenia, physicians prescribed bisphosphonate drugs (primarily alendronate, aka Fosamax) and hormone replacement therapy to help “prevent” osteoporosis. This practice exposed millions of women to the harms of medication — including blood clots, strokes, and serious infections — without any clear benefit.

Wait until you are 65 to get a BD test; at this point, the test can track bone loss at a time when it is most likely to be a threat to women’s health.

The BD test usually isn’t necessary in younger people without risk factors for weak bones.

As noted, most young women don’t need a BD test. For women at higher risk of decreased bone density, however, BD tests can provide useful information. These women include those who have taken high-dose steroids (like prednisone) to treat severe arthritis or asthma; who have taken drugs (like omeprazole) to treat acid reflux disease; and who have had an eating disorder, especially in their teens and 20s, when BD should be increasing most rapidly. Other women at higher risk include smokers and heavy alcohol users. Individuals with these risk factors need to discuss, with their health care provider, the possible benefit of BD testing before age 65.

A DEXA scan can pose risks and be a waste of money.

First, a word on what a DEXA scan’s results mean. The results are usually given as a “T-score,” which compares your bone density to that of normal women in their early 30s. (“Z-scores” compare your bone density to women in your age group.) T-scores are usually in the negative (or minus) range: the lower your T-score, the lower your bone density.

CW connects the dots in the way that makes sense: The DEXA scan is not expensive, as medical tests go (about $132, per the CW website), and the radiation exposure is much, much lower than a CT scan. (See “Watch out for CT Scans,” WHA, September 2012.) But, with a DEXA scan, it’s the medications prescribed to treat low BD that can be harmful.

Alendronate and other drugs in this class have serious risks of side effects and put women at risk for unusual and severe fractures because they halt the bodies’ natural, continuous process of bone remodeling. Even though research clearly shows that someone who has taken alendronate for 10 years receives no more benefit than when the drug is taken for 5 years, patients may be prescribed these medications for decades!

Bonus Comment: CW does not address how often to have a BD test after your first one (which preferably occurs at age 65 or older). If your BD score is “very low” (T-score -2 to -2.49), possibly get tested every 2 years.  If you are 65 or older and your initial test shows a “borderline low” BD (T-score -1.5 to -1.99), and you have no reason for accelerated bone loss, wait 3-5 years before having another BD test. If you have “normal”  BD (T-score  -1.01 to -1.49), you are off the BD testing track for 10 to 15 years! Remember, “normal” means you have the same bone density as women in their 30s.

Conclusion

What can you do to keep your bones healthy? That’s an entire article in itself, but, briefly, CW recommends:

  • Do weight-bearing exercise for at least 30 minutes daily
  • Take calcium (at least 1200 mg/day) and Vitamin D (600 IU under age 70, 800 IU over age 70)
  • Avoid smoking and excessive alcohol consumption
  • Minimize bone-sapping medications: steroids, proton pump inhibitors (PPIs) like omeprazole, and certain new antidepressants
  • Reduce your risk of falling by improving home safety: using brighter lights, eliminating clutter,  and using rubber mats in the bathroom. Have your vision checked and consider activities that improve strength and balance (Tai Chi, yoga, Pilates).

Charlea T. Massion, MD, is a NWHN Board member, family physician, hospitalist, and specialist in hospice and palliative care medicine. She is the Chief Medical Director of Hospice of Santa Cruz County and also teaches physicians about work-life balance and career development. Adriane Fugh-Berman, MD, is an associate professor in the Georgetown University Medical Center, a former chair of the NWHN, and director of PharmedOut, which  educates prescribers about pharmaceutical marketing techniques.


References

i.  Choosing Wisely®, an initiative of the AMIB; on-line at: http://www.choosingwisely.org

ii. Choosing Wisely® Lists (Things Physicians and Providers Should Question) are available at:  http://www.choosingwisely.org/doctor-patient-lists.