Dr. Juan J Dr. Juan J JallerJaller

Actualizacion en Actualizacion en densitometria densitometria

WHO Classification ofWHO Classification ofPostmenopausal OsteoporosisPostmenopausal Osteoporosis

Published in 1994 by a working group of Published in 1994 by a working group of the WHO the WHO

Intended to assess the prevalence of the Intended to assess the prevalence of the disease in a populationdisease in a population

Evaluated postmenopausal Caucasian Evaluated postmenopausal Caucasian females using DXA of spine, hip or females using DXA of spine, hip or forearmforearm

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World Health Organization. Technical Report Series 843WHO, Geneva.1994.

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WHO Classification ofPostmenopausal Osteoporosis

T- score (SD)

Normal Equal to -1.0 or higher

Low Bone Mass (Osteopenia)

Between -1.0 and -2.5

Osteoporosis Equal to -2.5 or lower

Severe Osteoporosis Equal to -2.5 or lower with fracture

World Health Organization. Technical Report Series 843WHO, Geneva.1994.

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• Number of standard deviations patient’s BMD is above or below average BMD of young-adult reference population

• T-score =

• Used for diagnosis

• If low, does not necessarily imply prior bone loss

T-score

BMD patient – BMD young-normal reference SD young-normal reference

Z-scoreZ-score Number of standard deviations patient’s BMD is Number of standard deviations patient’s BMD is

above or below average BMD of age-matched above or below average BMD of age-matched reference populationreference population

Z-score = Z-score =

Not used for diagnosisNot used for diagnosis

There is no evidence to support a specific cut-There is no evidence to support a specific cut-point to evaluate for secondary causes*.point to evaluate for secondary causes*. Secondary causes should always be considered Secondary causes should always be considered as clinically indicated.as clinically indicated.

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BMD patient – BMD age matched reference

SD age matched reference

*Tannenbaum. J Clin Endocrinol Metab. 2002;87(10):4431

Why Use T-score Instead of Why Use T-score Instead of Z-score for Diagnosis?Z-score for Diagnosis?

Bone density declines with ageBone density declines with age

Using Z-score for diagnosis would Using Z-score for diagnosis would suggest that the prevalence of suggest that the prevalence of osteoporosis does not increase with osteoporosis does not increase with ageage

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Score

T = −2.0 Z = −0.5

0.0

-1.0

-2.0

-3.0

+1.0

T

Z

20 40 60 80 100

1.200

0.960

0.840

-4.00.720

1.080

1.320

BMD gm/cm2 Spine: L1-L4

Age3

T-score T-score Equal to or Lower Equal to or Lower

Than Than −−2.5 2.5 Is Not Always Is Not Always Due to Primary Due to Primary OsteoporosisOsteoporosis

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Central DXA for Diagnosis: Central DXA for Diagnosis:

Skeletal Sites to MeasureSkeletal Sites to Measure Measure BMD at both lumbar spine and hip Measure BMD at both lumbar spine and hip in all patientsin all patients

Measure forearm BMD when:Measure forearm BMD when:

Lumbar spine and/or hip cannot be measured Lumbar spine and/or hip cannot be measured or interpretedor interpreted

HyperparathyroidismHyperparathyroidism

Very obese patients (over the weight limit for Very obese patients (over the weight limit for DXA table)DXA table)

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Central DXA for Central DXA for Diagnosis: Diagnosis:

Spine Region of Spine Region of InterestInterest Use L1-L4 for spine BMD measurementUse L1-L4 for spine BMD measurement

Use all evaluable vertebrae and only exclude Use all evaluable vertebrae and only exclude vertebrae affected by structural change or vertebrae affected by structural change or artifactartifact

Use 3 vertebrae if 4 cannot be used, and 2 if 3 Use 3 vertebrae if 4 cannot be used, and 2 if 3 cannot be usedcannot be used

Lateral spine should not be used for diagnosisLateral spine should not be used for diagnosis

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Central DXA for Diagnosis: Central DXA for Diagnosis:

Hip Region of InterestHip Region of Interest Use total proximal femur or femoral neck, Use total proximal femur or femoral neck, whichever is lowest whichever is lowest

BMD may be measured at either hipBMD may be measured at either hip

Do not use Ward’s area or the greater Do not use Ward’s area or the greater trochanter for diagnosistrochanter for diagnosis

Mean hip BMD can be used for monitoring Mean hip BMD can be used for monitoring with total hip preferred ROIwith total hip preferred ROI

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Central DXA for Diagnosis: Central DXA for Diagnosis:

Forearm Region of Forearm Region of InterestInterest

Use 33% radius (sometimes called one-Use 33% radius (sometimes called one-third radius) on the non-dominant third radius) on the non-dominant forearm as alternative siteforearm as alternative site

Other forearm ROIs are not recommendedOther forearm ROIs are not recommended

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Diagnosis in Premenopausal WomenDiagnosis in Premenopausal Women(age 20 and older) (age 20 and older)

WHO classification should not be applied to WHO classification should not be applied to healthy premenopausal womenhealthy premenopausal women

For women prior to menopause, Z-scores, rather For women prior to menopause, Z-scores, rather than T-scores, are preferred. This is particularly than T-scores, are preferred. This is particularly important in children.important in children.

A Z-score of -2.0 or lower is defined as “below the A Z-score of -2.0 or lower is defined as “below the expected range for age” and a Z-score above -2.0 expected range for age” and a Z-score above -2.0 is “within the expected range for age.” is “within the expected range for age.”

C 16ISCD 2005 Position Statement. Vancouver, B.C.

BMD Reporting in Females Prior to BMD Reporting in Females Prior to Menopause and in Males Younger Menopause and in Males Younger

Than Age 50Than Age 50

Z-scores, not T-scores, are preferred. This is Z-scores, not T-scores, are preferred. This is particularly important in children.particularly important in children.

A Z-score of -2.0 or lower is defined as “below the A Z-score of -2.0 or lower is defined as “below the expected range for age”, and a Z-score above -expected range for age”, and a Z-score above -2.0 is “within the expected range for age.”2.0 is “within the expected range for age.”

Osteoporosis cannot be diagnosed in men under Osteoporosis cannot be diagnosed in men under age 50 on the basis of BMD alone.age 50 on the basis of BMD alone.

The WHO diagnostic criteria may be applied to The WHO diagnostic criteria may be applied to women in the menopausal transition.women in the menopausal transition.

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Skeletal Sites to Measure Skeletal Sites to Measure for Diagnosis in Childrenfor Diagnosis in Children

Patients should have spine and total body Patients should have spine and total body less head (TBLH) BMC and areal BMD less head (TBLH) BMC and areal BMD measuredmeasured

The total hip is not a reliable site in The total hip is not a reliable site in growing children due to significant growing children due to significant variability in skeletal development and lack variability in skeletal development and lack of reproducible regions of interestof reproducible regions of interest

18Gordon C, et. al., J Clin Densitom; 2008; 11:43-58

DXA Interpretation and DXA Interpretation and Reporting in Children and Reporting in Children and

Adolescents (9) Adolescents (9) o The term “osteoporosis” should not appear in The term “osteoporosis” should not appear in

pediatric DXA reports without knowledge of pediatric DXA reports without knowledge of clinically significant fracture history.clinically significant fracture history.

o ““Low bone mineral content or bone mineral Low bone mineral content or bone mineral density for chronologic age” is the preferred density for chronologic age” is the preferred term when BMC or BMD Z-scores are less than term when BMC or BMD Z-scores are less than or equal to -2.0. or equal to -2.0.

DXA Interpretation and DXA Interpretation and Reporting in Children and Reporting in Children and

Adolescents (2) Adolescents (2) The hip (including total hip and proximal femur) The hip (including total hip and proximal femur)

is not a reliable site for measurement in is not a reliable site for measurement in growing children due to significant variability in growing children due to significant variability in skeletal development and lack of reproducible skeletal development and lack of reproducible ROI.ROI.

In children with linear growth or maturational In children with linear growth or maturational delay, spine and TBLH BMC and areal BMD delay, spine and TBLH BMC and areal BMD results should be adjusted for absolute height results should be adjusted for absolute height or height age, or compared to pediatric or height age, or compared to pediatric reference data that provide age-, gender-, and reference data that provide age-, gender-, and height-specific Z-scores. height-specific Z-scores.

DXA Interpretation and DXA Interpretation and Reporting in Children and Reporting in Children and

Adolescents (8) Adolescents (8) TerminologyTerminology

o T-scores should not appear in pediatric DXA T-scores should not appear in pediatric DXA reports.reports.

o The term “osteopenia” should not appear in The term “osteopenia” should not appear in pediatric DXA reports.pediatric DXA reports.

o The term “osteoporosis” should not appear in The term “osteoporosis” should not appear in pediatric DXA reports without knowledge of pediatric DXA reports without knowledge of clinically significant fracture history.clinically significant fracture history.

o ““Low bone mineral content or bone mineral density Low bone mineral content or bone mineral density for chronologic age” is the preferred term when for chronologic age” is the preferred term when BMC or BMD Z-scores are less than or equal to -2.0. BMC or BMD Z-scores are less than or equal to -2.0.

Diagnosis in Men: ISCD Diagnosis in Men: ISCD Position Position

Age 50 and older:Age 50 and older:

T-scores are preferred.T-scores are preferred.

The WHO densitometric classification is The WHO densitometric classification is applicable.applicable.

In men younger than age 50:In men younger than age 50:

Z-scores, not T-scores are preferred.Z-scores, not T-scores are preferred.

Osteoporosis cannot be diagnosed on the basis of Osteoporosis cannot be diagnosed on the basis of BMD alone.BMD alone.

C 23www.iscd.org

Indications for VFA Indications for VFA

Consider VFA when the results may influence Consider VFA when the results may influence clinical management.clinical management.

Postmenopausal women with low bone mass Postmenopausal women with low bone mass (osteopenia) by BMD criteria, PLUS any one of (osteopenia) by BMD criteria, PLUS any one of the following:the following:

o Age greater than or equal to 70 yearsAge greater than or equal to 70 yearso Historical height loss greater than 4 cm (1.6 in.)Historical height loss greater than 4 cm (1.6 in.)o Prospective height loss greater than 2 cm (0.8 in.)Prospective height loss greater than 2 cm (0.8 in.)o Self-reported vertebral fracture (not previously Self-reported vertebral fracture (not previously

documented)documented)

FRAX is a computer-based algorithm which uses easily obtained clinical risk factorsto estimate an individual’s 10-year fracture probability.It may be utilized by clinicians to assist in the identification of patients at high risk forfractures.

INTRODUCTORY STATEMENT

Strengths:Strengths:

The FRAX model determines the predictive The FRAX model determines the predictive importance of each clinical risk factor, as well as importance of each clinical risk factor, as well as interactions between them, to optimize the interactions between them, to optimize the accuracy of fracture probability.accuracy of fracture probability.

It is primarily used as a clinical tool to help It is primarily used as a clinical tool to help physicians assess fracture probability. physicians assess fracture probability.

FRAX aid in identifying which individuals may be FRAX aid in identifying which individuals may be candidates for bone density evaluation or candidates for bone density evaluation or pharmacological treatment. pharmacological treatment.

Limitations:Limitations:

FRAX does not take into account all risk variables ( ex. falls, FRAX does not take into account all risk variables ( ex. falls, markers of bone turnover levels, other bone density markers of bone turnover levels, other bone density assessments, as well as certain secondary causes of assessments, as well as certain secondary causes of osteoporosis).osteoporosis).

FRAX uses yes/no answers and the average risk is computed. FRAX uses yes/no answers and the average risk is computed.

Does not take into account the variation of risks associated Does not take into account the variation of risks associated with high or low doses of glucocorticoids, the number and with high or low doses of glucocorticoids, the number and type of prior fractures, or the quantity of alcohol or tobacco type of prior fractures, or the quantity of alcohol or tobacco consumption.consumption.

2010 ISCD-IOF FRAX Initiative and 2010 ISCD-IOF FRAX Initiative and

ISCD Position Development ConferenceISCD Position Development Conference

Bucharest, RomaniaBucharest, Romania

November 12-14, 2010November 12-14, 2010

Sanford Baim, MDSanford Baim, MD

Associate Professor of MedicineAssociate Professor of Medicine

Division of EndocrinologyDivision of Endocrinology

University of Miami, Miller School of MedicineUniversity of Miami, Miller School of Medicine

FRAX may underestimate fracture probability in individuals with a parental history of non-hip fragility fracture.

Bone turnover markers are not included as risk factors in FRAX.

FRAX CLINICAL STATEMENTS

Case 1a:Case 1a:

58 year old women.58 year old women.

8 years beyond menopause. 8 years beyond menopause.

Weight 60.5 Kg.Weight 60.5 Kg.

No personal or family history of fracture.No personal or family history of fracture.

BMD FN T-score = BMD FN T-score = -2.4-2.4

Case 1b:Case 1b:

77 year old women.77 year old women.

Weight 53.6 Kg..Weight 53.6 Kg..

Mother experienced a hip fracture.Mother experienced a hip fracture.

BMD: FN T-score = BMD: FN T-score = -1.4-1.4

Steroid & Multi fracturesSteroid & Multi fractures

Paciente varon 53 años, con antecedentes de (LES) lupus Paciente varon 53 años, con antecedentes de (LES) lupus eritematoso sistemico en tratamiento a largo plazo con dosis eritematoso sistemico en tratamiento a largo plazo con dosis altas de prednisonaaltas de prednisona

T-score columna Lumbar -1.6T-score columna Lumbar -1.6 T-score Cuello femoral -1.0 ( 2005)T-score Cuello femoral -1.0 ( 2005) T-score cuello femoral -1.6 ( 2007)T-score cuello femoral -1.6 ( 2007)

Edad 51 a. / 2005

Steroid & Multi fractures

Steroid & Multi fractures

Steroid & Multi fractures

Inicial 1-23-02 Estudio Actual 11-08-07Steroid & Multi fractures

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PDC declaraciónPDC declaración

Existe correlacion entre el uso de corticoides por mas de 3 meses y el Existe correlacion entre el uso de corticoides por mas de 3 meses y el riesgo de fracturariesgo de fractura

El promedio de dosis de corticoides incorporado en el FRAX es de 2.5 a El promedio de dosis de corticoides incorporado en el FRAX es de 2.5 a 7.5 mg dia de prednisona o su equivalente7.5 mg dia de prednisona o su equivalente

la probabilidad de fractura es subestimada cuando la la probabilidad de fractura es subestimada cuando la dosis de prednisona es mayor de 7.5 mg/dia, y es dosis de prednisona es mayor de 7.5 mg/dia, y es sobre estimada cuando la dosis de prednisona es sobre estimada cuando la dosis de prednisona es

menor de 2.5 mg/diamenor de 2.5 mg/dia

reflexionesreflexiones

Debilidad sobre la dicotomía del uso del esteroideDebilidad sobre la dicotomía del uso del esteroide FRAX asume un promedio de dosis expuesta de esteroides FRAX asume un promedio de dosis expuesta de esteroides

(equivalente a la dosis media de GPRD)(equivalente a la dosis media de GPRD) > 7.5 mg de prednisona dia , indica mayor riesgo de fractura > 7.5 mg de prednisona dia , indica mayor riesgo de fractura

que el que predice el FRAX. que el que predice el FRAX.

Caso 1 reflexión Caso 1 reflexión

Debilidad sobre la dicotomia del uso del esteroideDebilidad sobre la dicotomia del uso del esteroide FRAX asume un promedio de dosis de esteroidesFRAX asume un promedio de dosis de esteroides > 7.5 mg de prednisona dia , indica mayor riesgo de fractura > 7.5 mg de prednisona dia , indica mayor riesgo de fractura

que el que predice el FRAX. que el que predice el FRAX.

L a Obesidad podria no ser protectoraL a Obesidad podria no ser protectora

la masa muscular puede no incrementarse con el pesola masa muscular puede no incrementarse con el peso

“Cuando Q

UEREMOS INTERPRETAR POSIBILI

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NECESARIO U

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UICIO C

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“Cuando Q

UEREMOS INTERPRETAR POSIBILI

DADES, ES

NECESARIO U

TILIZAR EL J

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Caidas multiples Caidas multiples

Varon 76 a. con antecedentes de múltiples caídas, Varon 76 a. con antecedentes de múltiples caídas, hipertensión, hiperlipidemia, osteoartritis de rodilla y hipertensión, hiperlipidemia, osteoartritis de rodilla y cadera, nicturia.cadera, nicturia. 25(oh) D = 26 ng/ml25(oh) D = 26 ng/ml AtorvastatinaAtorvastatina ASAASA HCTZHCTZ metoprololmetoprolol AlprazolanAlprazolan multivitaminamultivitamina

Caidas multiples

PDC declaraciónPDC declaraciónPDC declaraciónPDC declaración

Las caídas son un factor de riesgo para fracturas, pero no Las caídas son un factor de riesgo para fracturas, pero no están incorporada como variable en el actual modelo de están incorporada como variable en el actual modelo de FRAX. La probabilidad de fractura podría estar subestimada FRAX. La probabilidad de fractura podría estar subestimada en individuos con historia de caídas frecuentes, pero la en individuos con historia de caídas frecuentes, pero la cuantificación de este riesgo actualmente no es posiblecuantificación de este riesgo actualmente no es posible

Las caídas son un factor de riesgo para fracturas, pero no Las caídas son un factor de riesgo para fracturas, pero no están incorporada como variable en el actual modelo de están incorporada como variable en el actual modelo de FRAX. La probabilidad de fractura podría estar subestimada FRAX. La probabilidad de fractura podría estar subestimada en individuos con historia de caídas frecuentes, pero la en individuos con historia de caídas frecuentes, pero la cuantificación de este riesgo actualmente no es posiblecuantificación de este riesgo actualmente no es posible

reflexiónreflexiónreflexiónreflexión

Tratamiento con benzodiacepinaTratamiento con benzodiacepina Realmente la necesita?Realmente la necesita?

BPH con nicturiaBPH con nicturia Es necesario el diuretico?Es necesario el diuretico?

En dos antiipertensivosEn dos antiipertensivos Es ortostatica? Es ortostatica?

Tratamiento con benzodiacepinaTratamiento con benzodiacepina Realmente la necesita?Realmente la necesita?

BPH con nicturiaBPH con nicturia Es necesario el diuretico?Es necesario el diuretico?

En dos antiipertensivosEn dos antiipertensivos Es ortostatica? Es ortostatica?

Caso 2 reflexionesCaso 2 reflexiones

Riesgo de fractura parece ser mas elevado que el calculado Riesgo de fractura parece ser mas elevado que el calculado por FRAXpor FRAX

Necesita realzmente los medicamentos para OSP?Necesita realzmente los medicamentos para OSP? Probablemnte reduciendo los medicamentos, evaluando la Probablemnte reduciendo los medicamentos, evaluando la

parte nutricional ( BMI de 20 Kg/m2), considerar terapia fisica parte nutricional ( BMI de 20 Kg/m2), considerar terapia fisica para fortalecimiento en MMII, evaluar por asistencia para para fortalecimiento en MMII, evaluar por asistencia para soporte y estabilidad.soporte y estabilidad.

Pensar s

obre el pacie

nte y no

solo so

bre la DMO o el c

alculo

FRAX

Discordancia CL / femurDiscordancia CL / femur

mujer 66 añosmujer 66 años

FumadoraFumadora

Menopausia 51 a.Menopausia 51 a.

Antecedentes de familiar de fracturaAntecedentes de familiar de fractura

HTA . En tto. Con amlodipinoHTA . En tto. Con amlodipino

Cuello femoral t-score -1.7Cuello femoral t-score -1.7 CL t-score – 3.5CL t-score – 3.5

Discordancia CL / femurDiscordancia CL / femur

Discordancia CL / femurDiscordancia CL / femur

Frax riesgo mayor 12 %

Acorde con las guías canadienses la paciente esta justo por debajo del corte del 20%

Pero…… CL t-score -3.5

Measurements other than BMD or T-score at the femoral neck by Dual-energy X-ray Absorptiometry (DXA) are not recommended for use in FRAX.

FRAX may underestimate or overestimate major osteoporotic fracture risk when lumbar spine T-score is much lower or higher (>1 Standard Deviation discrepancy) than femoral neck T-score

FRAX BMD STATEMENTS