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www.osteoporosis.ca
2005 OSC Recommendations for 2005 OSC Recommendations for Bone Mineral Density ReportingBone Mineral Density Reporting
Siminoski K, Leslie WD, Brown JP, Frame H, Hodsman A, Josse RG, Khan A, Lentle BC, Levesque J, Lyons DJ, Tarulli G. Recommendations for Bone Mineral Density
Reporting in Canada. Can Assoc Radiol J 2005; 56: 178-188
Slides prepared bySlides prepared byKerry Siminoski, MD, FRCPCKerry Siminoski, MD, FRCPC
William Leslie, M.Sc., MD, FRCPCWilliam Leslie, M.Sc., MD, FRCPC
www.osteoporosis.ca
2002 Definitions: BMD Results
1. Kanis JA, et al. J Bone Miner Res 1994;9:1137-1141.2. WHO, Geneva 1994.
Status 1, 2 T-score
Normal +2.5 to −1.0, inclusive
Osteopenia Between −1.0 and −2.5
Osteoporosis ≤−2.5
Severe osteoporosis ≤−2.5 + fragility fracture
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Who Should Be Treated for Osteoporosis?
Long-term glucocorticoid
therapy
Long-term glucocorticoid
therapy
Start bisphosphonate
therapy
Start bisphosphonate
therapy
Obtain DXA BMD
for follow-up
Obtain DXA BMD
for follow-up
Personal historyof fragility fracture
after age 40
Personal historyof fragility fracture
after age 40
Low DXA BMD
(T-score <−2.5)
Low DXA BMD
(T-score <−2.5)
Clinical risk factors
(1 major or 2 minor)
Clinical risk factors
(1 major or 2 minor)
Non-traumaticvertebral
compressiondeformities
Non-traumaticvertebral
compressiondeformities
AND
Low DXA BMD (T-score <−1.5)
AND
Low DXA BMD (T-score <−1.5)
Consider therapy
Consider therapy
Repeat DXA BMDafter 1or 2 years
Repeat DXA BMDafter 1or 2 years
2002 OSC Guidelines2002 OSC Guidelines
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WHAT’S WRONG WITHT-SCORES?
Advantages
Unitless
Basis for the majority of osteoporosis guidelines
Simplicity
Disadvantages
Depends on site measured
Depends on technology
Depends on reference database—population mean
and standard deviation
Only includes BMD information and not additional
risk factors
Adapted from Faulkner K. Osteoporos Int 2005;16(4):347-52.
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Fracture RiskFracture Riskvs. BMDvs. BMDAt Different AgesAt Different Ages
Fracture RiskFracture Riskvs. BMDvs. BMDAt Different AgesAt Different Ages
BMD PREDICTS FRACTURESBMD PREDICTS FRACTURES
Hui et al. J Clin Invest 1988; 81:1804-9
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AGE T-Score
= -1.0
T-Score
= -2.5
50 6 % 11 %11 %
60 8 % 16 %
70 12 % 23 %
80 13 %13 % 26 %
Risk of Fractures Over 10 Years in WomenRisk of Fractures Over 10 Years in Women
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Proposed Change
• Previous OSC guidelines advised intervention based on WHO category as a marker of relative fracture risk.
• Now propose that an individual’s 10-year absolute fracture risk, rather than BMD alone, be used for fracture risk categorization
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Objective:Objective:
To propose a set of recommendations for optimal bone mineral density To propose a set of recommendations for optimal bone mineral density (BMD) reporting in postmenopausal women and older men to provide (BMD) reporting in postmenopausal women and older men to provide clinicians with both a BMD diagnostic category and a useful tool to clinicians with both a BMD diagnostic category and a useful tool to assess an individual’s risk of osteoporotic fractureassess an individual’s risk of osteoporotic fracture
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5-STEPS IN5-STEPS IN TREATING OSTEOPOROSISTREATING OSTEOPOROSIS
STEPS 1 and 2STEPS 1 and 2
Begin with the table appropriate for Begin with the table appropriate for the patient’s sex the patient’s sex Identify the row that is closest to Identify the row that is closest to the patient's agethe patient's age
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USING LOWEST T-SCORE TO FIND 10-YEAR USING LOWEST T-SCORE TO FIND 10-YEAR FRACTURE RISKFRACTURE RISK**
* L1-4 (minimum 2 valid vertebrae), total hip, trochanter and femoral neck
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USING LOWEST T-SCORE TO FIND 10-YEAR FRACTURE RISK USING LOWEST T-SCORE TO FIND 10-YEAR FRACTURE RISK - WOMEN- WOMEN
WOMEN
-4.5
-4.0
-3.5
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
50 55 60 65 70 75 80 85
AGE (years)
LO
WE
ST
T-S
co
re
Low RiskLow Risk
Moderate RiskModerate Risk
High RiskHigh Risk
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USING LOWEST T-SCORE TO FIND 10-YEAR FRACTURE RISKUSING LOWEST T-SCORE TO FIND 10-YEAR FRACTURE RISK
AGE LOW MODERATE HIGH<10% 10 to 20% >20%
50 >-3.4 <=-3.4 ---55 >-3.1 <=-3.1 ---60 >-3.0 <=-3.0 ---65 >-2.7 <=-2.7 ---70 >-2.1 -2.1 to -3.9 <-3.975 >-1.5 -1.5 to -2.9 <-3.280 >-1.2 -1.2 to -3.0 <-3.085 >-1.3 -1.3 to -3.3 <-3.3
MEN10-YEAR RISK
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USING LOWEST T-SCORE TO FIND 10-YEAR FRACTURE RISK USING LOWEST T-SCORE TO FIND 10-YEAR FRACTURE RISK - MEN- MEN
MEN
-4.5
-4.0
-3.5
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
50 55 60 65 70 75 80 85
AGE (years)
LOW
EST
T-Sc
ore
Low RiskLow Risk
High RiskHigh Risk
Moderate RiskModerate Risk
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CATEGORIZATION BASED ON 10-YEAR CATEGORIZATION BASED ON 10-YEAR FRACTURE RISKFRACTURE RISK
Absolute fracture risk in 10 years:
low: <10%
moderate: 10-20%
high: >20%
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5-STEPS IN5-STEPS IN TREATING OSTEOPOROSISTREATING OSTEOPOROSIS
STEP 3STEP 3
Determine the preliminary fracture risk Determine the preliminary fracture risk category by using the lowest T-score category by using the lowest T-score from the recommended skeletal sitesfrom the recommended skeletal sites
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5-STEPS IN5-STEPS IN TREATING OSTEOPOROSISTREATING OSTEOPOROSIS
STEP 4STEP 4
Evaluate clinical factors that may move Evaluate clinical factors that may move the patient into an even higher fracture the patient into an even higher fracture risk categoryrisk category
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Additional Clinical Factors
• Certain clinical factors increase fracture risk independent of BMD.
• The most important are:– Fragility fractures after age 40 (especially
vertebral compression fractures)– Systemic glucocorticoid therapy >3 months
duration.
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Additional Risk Factors
• Each factor effectively increases risk categorization to the next level:– from low risk to moderate risk, or– from moderate risk to high risk
• When both factors are present the patient should be considered at high risk regardless of the BMD result.
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5-STEPS IN5-STEPS IN TREATING OSTEOPOROSISTREATING OSTEOPOROSIS
STEP 5STEP 5
Determine the individual’s final Determine the individual’s final absolute fracture risk category.absolute fracture risk category.
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52 year-old woman52 year-old woman
CASE EXAMPLECASE EXAMPLE
Lowest T-score –2.7 in total hipLowest T-score –2.7 in total hip
BMD done because of menopause (age BMD done because of menopause (age 49) and family history of osteoporosis49) and family history of osteoporosis
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AGE LOW MODERATE HIGH<10% 10 to 20% >20%
50 >-2.3 -2.2 to -3.9 <-3.955 >-1.9 1.9 to -3.4 <-3.460 >-1.4 -1.4 to -3.0 <-3.065 >-1.0 -1.0 to -2.6 <-2.670 >-0.8 -0.8 to -2.2 <-2.275 >-0.7 -0.7 to -2.1 <-2.180 >-0.6 -0.6 to -2.0 <-2.085 >-0.7 -0.7 to -2.2 <-2.2
10-YEAR RISK
WOMEN
CASE EXAMPLECASE EXAMPLE
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High RiskHigh Risk
Moderate RiskModerate Risk
Low RiskLow Risk
WOMEN
-4.5
-4.0
-3.5
-3.0
-2.5
-2.0
-1.5
-1.0
-0.5
0.0
50 55 60 65 70 75 80 85
AGE (years)
LO
WE
ST
T-S
core
CASE EXAMPLECASE EXAMPLE
Low Risk
Moderate Risk
High Risk
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Fracture Risk CategoryFracture Risk CategoryModerate RiskModerate Risk
CASE EXAMPLECASE EXAMPLE
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Fracture Risk CategoryFracture Risk Category
High RiskHigh Risk
Moderate RiskModerate Risk
If Fragility Fracture HistoryIf Fragility Fracture History
CASE EXAMPLECASE EXAMPLE
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AGE LOW MODERATE HIGH<10% 10 to 20% >20%
50 >-2.3 -2.2 to -3.9 <-3.955 >-1.9 1.9 to -3.4 <-3.460 >-1.4 -1.4 to -3.0 <-3.065 >-1.0 -1.0 to -2.6 <-2.670 >-0.8 -0.8 to -2.2 <-2.275 >-0.7 -0.7 to -2.1 <-2.180 >-0.6 -0.6 to -2.0 <-2.085 >-0.7 -0.7 to -2.2 <-2.2
10-YEAR RISK
WOMEN
CASE EXAMPLECASE EXAMPLE
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In SummaryThe OSC Recommends:
•Individual’s 10-year absolute fracture risk, rather than BMD alone, be used for fracture risk categorization•Identify patient’s age/sex from table•Use lowest T-score to determine preliminary fracture risk•Evaluate other clinical factors that may move patient to higher risk category•Determine individual’s absolute fracture risk
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Endorsements
• Canadian Association of Nuclear Medicine
• Canadian Association of Radiologists
• Canadian Rheumatology Association
• International Society of Clinical Densitometry
• Society of Obstetricians and Gynecologists of Canada
• Canadian Society of Endocrinology and Metabolism
• Canadian Orthopedic Association
• College of Family Physicians of Canada