1. A Look at Osteoporosis Screening Guidelines Cynthia Phelan PGY 1 2003 08 07

2. Osteoporosis Systemic disease Low bone mass Micro-architectural deterioration of bone tissue Increased fragility Increase risk of fracture WHO – T-score lower than -2.5

3. Societal Impact 1 in 4 women 1 in 8 men Cause of over 70% of fractures in people over the age of 45 High cost to society for treatment of fractures and associated morbidity

4. Important for all patients! Prevention efforts must begin early Peak bone mass attained by the third decade Encourage exercise – resistance and impact Nutrition important Encourage Ca (1000 -1500mg) and Vit D (400 - 800 IU) supplementation in those who have poor dietary intake

5. Who to screen? Screen all who have one of … Age >65yrs Age >65yrs History of fragility fracture after age 40 History of fragility fracture after age 40 Osteoporosis in a first degree relative Osteoporosis in a first degree relative Thin build….BMI < 20 or wt < 57.8Kg Thin build….BMI < 20 or wt < 57.8Kg Early menopause (<45yrs) Early menopause (<45yrs) Chronic hypogonadism Chronic hypogonadism Chronic malnutrition / malabsorption Chronic malnutrition / malabsorption Chemotherapy (if long term survival expected) Chemotherapy (if long term survival expected)

6. Who to screen? Screen all who have one of … Glucocorticoid therapy Glucocorticoid therapy 7.5mg of prednisone per day for more than 3 months 7.5mg of prednisone per day for more than 3 months Cushing's Syndrome Cushing's Syndrome Prolonged use of anticonvulsants (>10yrs) Prolonged use of anticonvulsants (>10yrs) Documented loss of height Documented loss of height Development of kyphosis after menopause Development of kyphosis after menopause Primary hyperparathyroidism Primary hyperparathyroidism

7. Who to screen?? Screen patients who have two or more of.. Current smoking Current smoking History of hyperthyroidism History of hyperthyroidism Low calcium intake Low calcium intake Alcoholism Alcoholism Excessive caffeine intake Excessive caffeine intake

9. Who to screen?? 4 Key Risk Factors have been found to be most predictive of potential fracture related to osteoporosis Low Bone Mineral Density Low Bone Mineral Density Prior Fragility Fracture Prior Fragility Fracture Age >65 Age >65 Family History of Osteoporosis Family History of Osteoporosis

10. Screening Tools DEXA (Dual energy X-ray absorptiometry) Single most predictive test for identification of patients at risk Single most predictive test for identification of patients at risk Gold standard Gold standard Useful for assessing patient current BMD as compared to standard and for watching changes in pts BMD over time Useful for assessing patient current BMD as compared to standard and for watching changes in pts BMD over time Operator error may alter results Operator error may alter results Results may also be skewed by compression fractures Results may also be skewed by compression fractures

11. Screening Tools Peripheral Bone Density Testing Measured by DEXA or US at several sites (radius, phalanx, calcaneus) Measured by DEXA or US at several sites (radius, phalanx, calcaneus) Used more often in under serviced areas Used more often in under serviced areas Useful for predicting fracture risk Useful for predicting fracture risk Not good for following pts thus not a recommended screening tool to date Not good for following pts thus not a recommended screening tool to date

12. Screening Tools Blood and Urine Studies of bone turnover markers (CBC, Ca, Alk Phos, Creat) Useful to investigate secondary causes Useful to investigate secondary causes Individual patients show large variation in test results from one day to the next Individual patients show large variation in test results from one day to the next Cannot readily be used to identify patients at risk Cannot readily be used to identify patients at risk Not recommended as screening tools or as tools to monitor effect of therapy Not recommended as screening tools or as tools to monitor effect of therapy

13. Diagnosis Recommendations Patients at increased risk and those over age 65 should have BMD done via DEXA Patients at increased risk and those over age 65 should have BMD done via DEXA Peripheral US or DEXA should not be used for following patients Peripheral US or DEXA should not be used for following patients Additional studies are required before biochemical markers become a useful tool in screening and surveillance of osteoporosis Additional studies are required before biochemical markers become a useful tool in screening and surveillance of osteoporosis

14. Interpretation of Results BMD T-Score Change in # risk WHO Categorization > -1 -Normal -1 to -2.5 4x increase Osteopenia > -2.5 8x increase Osteoporosis 1+ fragility # 1+ fragility # 20x increase Severe Osteoporosis

15. When to start treatment Therapy used to prevent bone deterioration and reduce fractures Treating women with T-score less -2 or a T-score less than -1.5 with risk factors has been deemed cost effective. Clinical decision making must be made on a patient to patient basis.

16. Take Home Points Consider risk factors in all patients Screen patients who are at risk with DEXA Don’t neglect elderly patients with multiple medical problems – they may benefit greatly from therapy (even if they are resistant to additional medications) Consider Rx in all patients with t-score less than -1.5 (+risk factors) or -2.

17. Take Home Points Prevention, prevention, prevention Start very early! 1.Yuen CK et al. Canadian Consensus on Menopause and Osteoporosis. Osteoporosis. Journal of Obstetrics and Gynecology of Canada. 2002; 24(10): 35-44. 2.Brown JP et al. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ 2002; 167(10): S1-36.