to the editor: The clinical scenario presented in the Cochrane for Clinicians on alendronate (Fosamax) for fracture prevention in postmenopause was not consistent with the U.S. Preventive Services Task Force (USPSTF) recommendations. The patient in the clinical scenario was a 55-year-old woman with no history of a fracture and no other risk factors for osteoporosis. The USPSTF does not recommend testing women of this age for osteoporosis. The earliest age group in which they recommend testing is 60 to 64 years, and only if the patient is at increased risk for osteoporotic fractures.1 The USPSTF concluded that the balance of benefits and harms from screening and treatment was too close to make a general recommendation for this age group. Otherwise, they recommend routine screening once after age 65 years for all women.
The most significant risk factor for a fracture is olderage. The authors noted that alendronate was more effective with increasing age. Once bisphosphonate treatment is initiated, it may need to be continued for the remainder of the patient's life. Therefore, the decision to initiate pharmacologic therapy for women younger than 65 years should be based on more than the results of a dual-energy x-ray absorptiometry (DEXA) scan. Recently, an absolute fracture prediction algorithm (FRAX) was developed to identify patients at high risk of a fracture and for whom treatment would likely be beneficial.2 However, for patients older than 65 years, the use of the T-score alone yields similar recommendations.3
Fracture prevention begins soon after the start of bisphosphonate therapy and before there has been a significant increase in the bone mineral density.4 So, physicians should wait to test and treat patients until the benefit is significantly greater than the risk. I would have preferred the patient in the clinical scenario to be older than 60 years to reinforce the concept of waiting to test for osteoporosis until the age at which pharmacologic treatment is more likely to be beneficial.
editor's note: This letter was sent to the authors of “Alendronate for Fracture Prevention in Postmenopause,” who declined to reply.