USPSTF Issues Final Guidance on Preventing Falls, Fractures

April 18, 2018, 10:55 am News Staff – On April 17, the U.S. Preventive Services Task Force posted two final recommendation statements and evidence summaries on the prevention of falls and fractures in older adults.

This final recommendation statement updates the USPSTF's September 2017 draft and 2012 final recommendation statements. The recommendations for exercise and multifactorial interventions are consistent with the previous final recommendations; however, based on the current evidence, the task force now recommends against taking vitamin D to prevent falls.

A draft version of this recommendation statement was posted for public comment on the USPSTF website from Sept. 26 to Oct. 24, 2017.

In response to some commenters, the task force clarified that physical therapy, which was described separately from exercise interventions in the 2012 recommendation, is now included among "exercise interventions" in the current recommendation.

Additionally, the USPSTF clarified that these recommendations apply to older adults who are not known to be vitamin D deficient.

A few commenters asked for more details on effective exercise and multifactorial interventions.

"Given the heterogeneity of included interventions, it is difficult for the USPSTF to identify specific components that it found to be particularly effective; however, the USPSTF included results from some exploratory analyses," the final recommendation said.

Some commenters requested recommendations for other interventions, such as comprehensive eye examination and reducing medication prescriptions.

The USPSTF replied that it recommends interventions only when it finds supporting evidence that the benefits outweigh the harms.

"Although the USPSTF may have reviewed additional interventions, it did not find adequate evidence to issue a recommendation on all of the reviewed interventions," it said.

Supplementation to Prevent Fractures

Separately, the USPSTF issued a final recommendation statement and final evidence summary on supplementation for the primary prevention of fractures in community-dwelling adults who have no history of fractures related to osteoporosis.

Based on its review of the evidence, the task force found there wasn't enough evidence

• about the benefits and harms of vitamin D and calcium supplementation, alone or combined, to prevent fractures in men or premenopausal women -- an I statement; or
  
• to recommend for or against supplementation with higher doses of vitamin D and calcium (greater than 400 IU of vitamin D and greater than 1,000 mg of calcium) in community-dwelling, postmenopausal women – also an I statement.

Additionally, the USPSTF recommended against daily supplementation at lower doses (400 IU or less of vitamin D and 1,000 mg or less of calcium) for the primary prevention of fractures in community-dwelling, postmenopausal women -- a D recommendation.

The task force reviewed evidence from eight randomized, controlled trials on vitamin D, calcium or combined supplementation for the primary prevention of fractures; four evaluated vitamin D supplementation, two evaluated calcium supplementation and two evaluated combined vitamin D and calcium supplementation.

Four studies represented data from 5,900 men and four studies exclusively included women, with almost 42,000 women analyzed across all eight studies. The mean age of study participants ranged from 53-80 years.

"We found that taking low doses of vitamin D and calcium does not prevent women who have gone through menopause from getting fractures," said USPSTF member Carol Mangione, M.D., M.S.P.H., in the release. "We need more research to understand if taking higher doses of vitamin D or calcium helps to prevent fractures in women who have gone through menopause -- or at any dose for men or younger women."

This final recommendation statement is consistent with the task force's 2017 draft and 2013 final recommendation statement on this topic.

A draft version of this final recommendation statement was posted on the USPSTF's website during the same timeframe as the previously mentioned recommendation.

Some commenters said they were concerned that the recommendation against supplementation with vitamin D would be misinterpreted by patients with known osteoporosis or vitamin D deficiency.

The USPSTF replied that patients with known osteoporosis or vitamin D deficiency were excluded from the evidence review, and thus are excluded from the recommendation statement.

Other commenters requested clarification on the role of vitamin D in patients with known osteoporosis or vitamin D deficiency. The USPSTF said this was beyond the scope of the recommendation, and clarified that under the Scope of Review subhead.

Some commenters also expressed confusion about why the task force said there was insufficient evidence for supplementation at higher doses if the USPSTF recommends against supplementation at lower doses.

"The recommendation against supplementation at lower doses was based on an overall assessment that supplementation at low doses provides no benefit," the final recommendation said. "Evidence on the effect of supplementation on fractures at higher doses is conflicting, with some studies showing a reduction in certain fracture types at higher doses, and others showing no reduction or even an increase."

The USPSTF concluded that more studies are needed to better determine if supplementation with vitamin D, calcium or both consistently prevents fractures.

"If future evidence shows a benefit, the magnitude of that benefit will need to be weighed against the magnitude of harms caused by supplementation (kidney stones)," the recommendation said.

The AAFP plans to review the USPSTF's final recommendation statements and supporting evidence and subsequently release its own recommendations on the topics.