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www.osteoporosis.ca 2005 OSC Recommendations for 2005 OSC Recommendations for Bone Mineral Density Reporting 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: 178-188 Slides prepared by Slides prepared by Kerry Siminoski, MD, FRCPC Kerry Siminoski, MD, FRCPC William Leslie, M.Sc., MD, FRCPC William Leslie, M.Sc., MD, FRCPC

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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

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2002 Definitions: BMD Results

1. Kanis JA, et al. J Bone Miner Res 1994;9:1137-1141.2. WHO, Geneva 1994.

T-scoreStatus 1, 2

≤−2.5 + fragility fractureSevere osteoporosis

≤−2.5Osteoporosis

Between −1.0 and −2.5Osteopenia

+2.5 to −1.0, inclusiveNormal

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Who Should Be Treated for Osteoporosis?

Long-term glucocorticoid

therapy

Start bisphosphonate

therapy

Obtain DXA BMD

for follow-up

Personal historyof fragility fracture

after age 40

Low DXA BMD

(T-score <−2.5)

Clinical risk factors

(1 major or 2 minor)

Non-traumaticvertebral

compressiondeformities

AND

Low DXA BMD (T-score <−1.5)

Consider therapy

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

BMD PREDICTS FRACTURESBMD PREDICTS FRACTURES

Hui et al. J Clin Invest 1988; 81:1804-9

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26 %13 %13 %80

23 %12 %70

16 % 8 %60

11 %11 % 6 %50

T-Score

= -2.5

T-Score

= -1.0

AGE

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 RiskModerate 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