OSC Recommendations for Bone Mineral Density Reporting Slides prepared by Kerry Siminoski, MD, FRCPC William Leslie, M.Sc., MD, FRCPC 2005 OSC Recommendations for Bone 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: Slides prepared by Kerry Siminoski, MD, FRCPC William Leslie, M.Sc., MD, FRCPC

Definitions: BMD Results 1. Kanis JA, et al. J Bone Miner Res 1994;9: WHO, Geneva Status 1, 2 T-score Normal+2.5 to −1.0, inclusive OsteopeniaBetween −1.0 and −2.5 Osteoporosis≤−2.5 Severe osteoporosis≤−2.5 + fragility fracture

Who Should Be Treated for Osteoporosis? Long-term glucocorticoid therapy Start bisphosphonate therapy Start bisphosphonate therapy Obtain DXA BMD for follow-up Personal history of fragility fracture after age 40 Low DXA BMD (T-score <−2.5) Clinical risk factors (1 major or 2 minor) Non-traumatic vertebral compression deformities AND Low DXA BMD (T-score <−1.5) AND Low DXA BMD (T-score <−1.5) Consider therapy Consider therapy Repeat DXA BMD after 1or 2 years 2002 OSC Guidelines

WHAT’S WRONG WITH T-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):

Fracture Risk vs. BMD At Different Ages Fracture Risk vs. BMD At Different Ages BMD PREDICTS FRACTURES Hui et al. J Clin Invest 1988; 81:1804-9

AGET-Score = -1.0 T-Score = % 11 % 60 8 %16 % 7012 %23 % % 26 % Risk of Fractures Over 10 Years in Women

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

Objective: To propose a set of recommendations for optimal bone mineral density (BMD) reporting in postmenopausal women and older men to provide clinicians with both a BMD diagnostic category and a useful tool to assess an individual’s risk of osteoporotic fracture

5-STEPS IN 5-STEPS IN TREATING OSTEOPOROSIS TREATING OSTEOPOROSIS STEPS 1 and 2 STEPS 1 and 2 Begin with the table appropriate for the patient’s sex Identify the row that is closest to the patient's age

USING LOWEST T-SCORE TO FIND 10-YEAR FRACTURE RISK * * L1-4 (minimum 2 valid vertebrae), total hip, trochanter and femoral neck

USING LOWEST T-SCORE TO FIND 10-YEAR FRACTURE RISK - WOMEN Low Risk Moderate Risk High Risk

USING LOWEST T-SCORE TO FIND 10-YEAR FRACTURE RISK

USING LOWEST T-SCORE TO FIND 10-YEAR FRACTURE RISK - MEN Low Risk High Risk Moderate Risk

CATEGORIZATION BASED ON 10-YEAR FRACTURE RISK Absolute fracture risk in 10 years: low: <10% moderate: 10-20% high: >20%

5-STEPS IN 5-STEPS IN TREATING OSTEOPOROSIS TREATING OSTEOPOROSIS STEP 3 STEP 3 Determine the preliminary fracture risk category by using the lowest T-score from the recommended skeletal sites

5-STEPS IN 5-STEPS IN TREATING OSTEOPOROSIS TREATING OSTEOPOROSIS STEP 4 STEP 4 Evaluate clinical factors that may move the patient into an even higher fracture risk category

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.

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.

5-STEPS IN 5-STEPS IN TREATING OSTEOPOROSIS TREATING OSTEOPOROSIS STEP 5 STEP 5 Determine the individual’s final absolute fracture risk category.

52 year-old woman CASE EXAMPLE Lowest T-score –2.7 in total hip BMD done because of menopause (age 49) and family history of osteoporosis

CASE EXAMPLE

High Risk Moderate Risk Low Risk CASE EXAMPLE Low Risk Moderate Risk High Risk

Fracture Risk Category Moderate Risk CASE EXAMPLE

Fracture Risk Category High Risk Moderate Risk If Fragility Fracture History CASE EXAMPLE

CASE EXAMPLE

In Summary The 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

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