重複測量BMD對大多數老年女性是不需要的


  Sept. 28, 20005 (那什維爾訊)-根據一項發表於美國骨骼與礦物質研究學會第27屆年會的試驗結果,大部分65歲以上的女性並不需要以重複測量骨質密度(BMD)來評估發生骨折的風險。
  
  目前的指引建議65歲以上的女性需要測量BMD,而且許多醫師對這群病患每2至3年就測量一次BMD;但是一項收納將近1萬名女性的臨床試驗結果顯示,當65歲以上女性應該進行BMD檢驗時,這群病患重複進行檢驗並沒有更多的好處。
  
  首席研究者奧勒岡州波特蘭Kaiser Permanente健康研究中心的Teresa Hillier醫師表示,BMD是預測骨折風險一項很好的檢驗,但是老年病患在做過一次檢驗後,需要重複檢驗嗎?根據這項研究結果,65歲以上女性並不需要第2次BMD檢驗。
  
  國家骨質疏鬆治療指引建議,所有65歲以上的女性,不論是否有危險因子都應該接受BMD檢驗;保險制度允許適齡婦女每2年接受一次檢驗。
  
  奧勒岡研究團隊追蹤4項臨床試驗中9,704位65歲以上女性,在一項前瞻性世代研究中,婦女於1986年、1988至1990年及之後的8年接受雙向X射線吸收計檢驗。
  
  除此之外,2,193位婦女於1991至1992年接受側向脊椎X射線檢驗,並在5年後再檢驗一次。
  
  研究者分析骨折與起始BMD、後續追蹤BMD以及BMD變化之間的關係。
  
  在後續追蹤BMD後,877位女性發生非創傷非脊椎骨折,其中275位是骨盆骨折;再校正年齡、體重後,起始BMD與後續追蹤BMD在預測非脊椎、脊椎、及骨盆骨折風險上是相似的。
  
  這樣的模式可以預測骨折風險,起始BMD每降低一個標準差,發生骨折的風險就上升1.5至2.0倍;骨折發生率的風險也是類似的,起始BMD與後續追蹤BMD在預測非脊椎骨折上的危險比例為1.5至1.6,脊椎骨折的整體風險為1.7至1.8,而骨盆骨折的風險為2.0至2.2。
  
  接受操作特徵曲線顯示,BMD檢驗的敏感度與專一性,在作為脊椎骨折、非脊髓骨折與骨盆骨折的起始檢驗上,後續追蹤BMD與起始及後續追蹤BMD之間差異的曲線下面積(AUC)是相似的。
  
  Hillier醫師在發表這項結果時表示,每一組的曲線都是重疊的,顯示預測骨折的資訊基本上是相似的。
  
  她提醒這項結果僅能應用在年齡較大的病患身上,而且BMD檢驗的需求,在65歲以下停經前與停經後婦女可能是很不同的;在那段期間的女性所發生的事情可能與年齡較大女性的不同,一旦婦女確定已經停經,她們骨質流失的速度仍然是固定的。
  
  她附帶表示,然而,如果65歲以上女性的健康情形突然改變,那可能需要更多的檢驗。
  
  舊金山加州大學流行病學與生物統計教授Dennis Black博士表示,這是項很好的試驗,顯示老年病患並不需要常規地監測BMD作為預測骨折的因子;65歲以上的婦女應該至少接受過一次BMD檢驗,之後只有在重大健康情況變化限制活動時、接受類固醇藥物治療時、以及因為許多原因而變得比較受限時接受重複BMD檢驗。

Repeat BMD Testing Not Require

By Linda Little
Medscape Medical News

Sept. 28, 20005 (Nashville) — Most women aged 65 years and older do not require repeat bone mineral density (BMD) tests to determine their fracture risk, according to a presentation at the American Society for Bone and Mineral Research 27th annual meeting.

Current guidelines recommend that women aged 65 years and older get a bone mineral density (BMD) test, and many physicians request one every two or three years for women in this age group. But a Kaiser Permanente study of nearly 10,000 women revealed that while women aged 65 years and older should be tested once, this age group does not necessarily benefit from repeated testing.

"BMD testing is very predictive of fractures, but is there any value in a second test in older women beyond the first test?" said lead investigator Teresa Hillier, MD, from Kaiser Permanente Center for Health Research in Portland, Oregon. "Based on this research, a second test isn't required in women over age 65."

National Osteoporosis Foundation guidelines recommend that all women aged 65 years and older receive BMD testing regardless of risk factors. The Medicare program permits women of this age to be tested every two years.

The Oregon team followed 9,704 women aged 65 years and older at four clinical sites. In a prospective cohort, the women received dual x-ray absorptiometry in 1986, 1988 to 1990, and than again eight years later.

In addition, 2,193 of the women had lateral spine x-rays in 1991-1992 and again five years later.

The researchers analyzed the association between fractures and initial BMD, follow-up BMD, and BMD plus the change between the initial and follow-up BMD.

After the follow-up BMD, 877 women suffered an incident of nontraumatic nonspinal fracture, of which 275 were hip fractures. Another 345 women had spinal fractures. After adjusting for age and weight, the risk for fracture was similar with initial BMD and follow-up BMD in the prediction of nonspinal, spinal and hip fractures.

The models were highly predictive of fracture, with a hazard model of 1.5 to 2.0 times the risk for every standard deviation decrease in the initial BMD. The risk of fracture incidence was similar, with the initial BMD and follow-up BMD for predicting nonspinal fractures with a hazard ratio of 1.5 to 1.6, spinal fracture with an overall risk of 1.7 to 1.8, and hip fractures with an hazard ratio of 2.0 to 2.2.

Receiver operator characteristics curves, which show sensitivity and specificity of tests across the range, revealed similar area under the curve (AUC) in follow-up BMD and the change between initial and follow-up BMD compared with the initial test for spine fracture, nonspine fracture, and hip fracture. Further stratification by initial BMD scores as normal, osteopenic, and osteoporotic did not reveal improvement in the AUC.

"The curves for each group were superimposed, revealing that the information predicting fracture essentially were the same," Dr. Hillier said during her presentation.

She warned that the results could only be applied to older women and the need for BMD testing may be very different in perimenopausal and postmenopausal women younger than 65 years. "What happens in that time period may clearly be different than in older women. Once a woman is clearly menopausal, they appear to remain stable in the rate of loss."

However, if a woman aged 65 years or older has a sudden change in health status, then another test may be required, she added.

"This is a good study that shows in older women you don't need to measure BMD regularly as a fracture predictor," said Dennis Black, PhD, a professor of epidemiology and biostatics at the University of California at San Francisco. "Women over 65 years should have at least one scan, then only repeat BMD scans if there is a large change in their health resulting in decreased mobility, treatment with steroids, or they become less active for a variety of reasons."

ASBMR 27th Annual Meeting: Abstract 1057. Presented Sept. 25, 2005.

Reviewed by Gary D. Vogin, MD

    
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