2005 OSC Recommendations for Bone Mineral Density Reporting Siminoski K, Leslie WD, Brown JP, Frame H, Hodsman A, Josse RG...
2002 Definitions: BMD Results 1. Kanis JA, et al.  J Bone Miner Res  1994;9:1137-1141. 2. WHO, Geneva   1994. T-score Stat...
Who Should Be Treated for Osteoporosis? Long-term  glucocorticoid  therapy Start  bisphosphonate therapy Obtain  DXA BMD f...
WHAT’S WRONG WITH T-SCORES? Advantages Unitless Basis for the majority of osteoporosis guidelines Simplicity Disadvantages...
Fracture Risk vs. BMD At Different Ages BMD PREDICTS FRACTURES Hui et al.  J Clin Invest 1988; 81:1804-9
Risk of Fractures Over 10 Years in Women 26 % 13 % 80 23 % 12 % 70 16 % 8 % 60 11 % 6 % 50 T-Score = -2.5 T-Score  = -1.0 ...
Proposed Change <ul><li>Previous OSC guidelines advised intervention based on WHO category as a marker of relative fractur...
Objective: To propose a set of recommendations for optimal bone mineral density (BMD) reporting in postmenopausal women an...
5-STEPS IN TREATING OSTEOPOROSIS STEPS 1 and 2 Begin with the table appropriate for the patient’s sex  Identify the row th...
USING LOWEST T-SCORE TO FIND 10-YEAR FRACTURE RISK * * L1-4 (minimum 2 valid vertebrae), total hip, trochanter and femoral...
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
<ul><li>Absolute fracture risk in 10 years: </li></ul><ul><li>low:  <10% </li></ul><ul><li>moderate:  10-20% </li></ul><ul...
5-STEPS IN TREATING OSTEOPOROSIS STEP 3 Determine the preliminary fracture risk category by using the lowest T-score from ...
5-STEPS IN TREATING OSTEOPOROSIS STEP 4 Evaluate clinical factors that may move the patient into an even higher fracture r...
Additional Clinical Factors <ul><li>Certain clinical factors increase fracture risk independent of BMD. </li></ul><ul><li>...
Additional Risk Factors <ul><li>Each factor effectively increases risk categorization to the next level: </li></ul><ul><ul...
5-STEPS IN TREATING OSTEOPOROSIS STEP 5 Determine the individual’s final absolute fracture risk category.
<ul><li>52 year-old woman </li></ul>CASE EXAMPLE Lowest T-score –2.7 in total hip BMD done because of menopause (age 49) a...
CASE EXAMPLE
High Risk Moderate Risk Low Risk CASE EXAMPLE Low Risk Moderate Risk High Risk
<ul><li>Fracture Risk Category </li></ul>Moderate Risk CASE EXAMPLE
<ul><li>Fracture Risk Category </li></ul>High Risk Moderate Risk If Fragility Fracture History CASE EXAMPLE
CASE EXAMPLE
 
In Summary The OSC Recommends: <ul><li>Individual’s 10-year absolute fracture risk, rather than BMD alone, be used for fra...
Endorsements <ul><li>Canadian Association of Nuclear Medicine </li></ul><ul><li>Canadian Association of Radiologists </li>...
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  • Speaker Notes: This presentation reviews the 2005 Osteoporosis Society of Canada’s “Recommendations for Bone Mineral Density Reporting”, published in the June 2005 edition of the Canadian Association of Radiologists journal. These recommendations were developed by a multidisciplinary working group under the auspices of the Scientific Advisory Council of the Osteoporosis Society of Canada and the Canadian Association of Radiologists. All recommendations were developed using a consensus from clinicians and experts in the field of BMD testing and a standard method for the evaluation and citation of the supporting evidence.
  • Speaker Notes In 2002 the OSC adopted the World Health Organization (WHO) study group’s definitions for BMD reporting. These were based on comparing an individual patient with a mean BMD for a normal young adult population of the same sex and race. The definition assigns the patient a T-score , which is the number of standard deviations (SDs) the patient’s BMD is above or below the mean, as follows: – N ormal: BMD T-score between +2.5 and − 1.0,inclusive – O steopenia (low BMD): BMD T-score between − 1.0 and − 2.5 – O steoporosis: BMD T-score at or lower than − 2.5. The WHO study group added a fourth category, severe osteoporosis , to describe patients whose T-score is at or below − 2.5 and who also have suffered a fragility fracture. The WHO has defined a fragility fracture as “a fracture caused by injury that would be insufficient to fracture normal bone: the result of reduced compressive and/or torsional strength of bone.” Clinically, a fragility fracture may be defined as one that occurs as a result of minimal or no identifiable trauma.
  • Speaker notes This slide shows an algorithm based on the 2002 OSC Clinical Practice Guidelines to determine who should have fracture risk assessment and be treated for osteoporosis. We now propose that an individual’s 10-year absolute fracture risk, rather than BMD alone, be used for fracture risk categorization. Consequently, age, sex, BMD, fragility fracture history, and glucocorticoid use are the basis for the approach outlined in this work. Initiatives are underway to integrate information about other clinical risk factors.
  • Speaker Notes:
  • Speaker Notes: Earlier studies have identified the relationship between age, BMD and fracture risk
  • Speaker Notes: Risk of Fractures Over 10 years in Women; This further illustrates the relationship of fracture risk and age. Note that in the absence of other risk factors, an 80 yr old woman with a T-score of –1.0 has a greater risk for fracture than a 50 yr old woman with a T-score of –2.5
  • Speaker Notes: 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 Use the 5 Steps in Treating Osteoporosis Slides to further clarify
  • Speaker Notes: Current methods of BMD reporting were reviewed. In this document, we propose that an individual’s 10 year absolute fracture risk, rather than BMD alone, be used to assess fracture risk . This information complements the standards developed by the Canadian Panel of the International Society for Clinical Densitometry (ISCD), establishing the minimum requirements for acceptable performance of BMD testing in Canada
  • Speaker Notes: Begin with the table appropriate for the patient’s sex Identify the row that is closest to the patient&apos;s age Next slide shows tables for women and men
  • Speaker Notes: Using the lowest T-score, and age, this table identifies the risk category for fracture risk for women over 50 yrs
  • Speaker Notes: Patient’s score can be plotted on the graph and level of fracture risk identified
  • Speaker Notes: Using the lowest T-score, and age, this table identifies the category for fracture risk for men over 50 yrs
  • The fracture risk category (low, moderate, high) is determined from the previous tables of corresponding T score and age. There are 3 categories for absolute risk: low (less than 10%, moderate (between 10-20%), and high (over 20%). Similar risk categories have been used for cardiovascular risk assessment.
  • Speaker Notes: Determine the preliminary fracture risk category by using the lowest T-score from the recommended skeletal sites
  • Speaker Notes: Evaluate clinical factors that may move the patient into an even higher fracture risk category
  • Speaker Notes: Certain risk factors increase fracture risk independent of BMD. The most important are: Fragility fractures after age 40 yrs (especially vertebral compression fractures) Systemic glucocorticoid therapy of &gt;3months duration
  • Speaker Notes: The presence of either of these factors substantially elevates fracture risk. Such factors effectively increase 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 to be at high risk regardless of the BMD result.
  • Speaker Notes:
  • Speaker Notes: Case Study: A 52 year old woman Menopause at age 49 Family History of osteoporosis (eg. Mother had fractured a hip at age 72) T-score: Hip –2.7 SD ; Lumbar Spine –2.0 SD The lowest T-score is used to assess BMD
  • Speaker Notes: Using the 10 year fracture risk model, locate her age and T-score on the table. She is in a moderate risk category.
  • Speaker Notes; Shown another way, this is where this patient plots on the graph
  • Based on her history, this patient would be in a Moderate Risk category
  • However, if she also presented with a fragility fracture, which is major risk factor for future fractures, she would move from Moderate Risk to High Risk (see next slide for table)
  • Speaker Notes: An sample patient questionnaire form. This summarizes pertinent questions that help to ensure a valid scan and report. The patient can easily complete the questionnaire while waiting for the BMD. Recommended for use in all BMD testing centres.
  • Speaker Notes: In Summary, the Osteoporosis Society of Canada 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 Since these are the first Canadian recommendations integrating clinical risk factors in a quantitative fracture risk assessment, this document should be considered a work in progress, as it is anticipated that the recommendations will be updated periodically to accommodate advances in this field.
  • Speaker Notes: These recommendations have been endorsed by, and are being incorporated into, the following associations
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    1. 1. 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: 178-188 Slides prepared by Kerry Siminoski, MD, FRCPC William Leslie, M.Sc., MD, FRCPC
    2. 2. 2002 Definitions: BMD Results 1. Kanis JA, et al. J Bone Miner Res 1994;9:1137-1141. 2. WHO, Geneva 1994. T-score Status 1, 2 ≤− 2.5 + fragility fracture Severe osteoporosis ≤− 2.5 Osteoporosis Between − 1.0 and − 2.5 Osteopenia +2.5 to − 1.0, inclusive Normal
    3. 3. Who Should Be Treated for Osteoporosis? Long-term glucocorticoid 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) Consider therapy Repeat DXA BMD after 1or 2 years 2002 OSC Guidelines
    4. 4. 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):347-52.
    5. 5. Fracture Risk vs. BMD At Different Ages BMD PREDICTS FRACTURES Hui et al. J Clin Invest 1988; 81:1804-9
    6. 6. Risk of Fractures Over 10 Years in Women 26 % 13 % 80 23 % 12 % 70 16 % 8 % 60 11 % 6 % 50 T-Score = -2.5 T-Score = -1.0 AGE
    7. 7. Proposed Change <ul><li>Previous OSC guidelines advised intervention based on WHO category as a marker of relative fracture risk. </li></ul><ul><li>Now propose that an individual’s 10-year absolute fracture risk, rather than BMD alone, be used for fracture risk categorization </li></ul>
    8. 8. 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
    9. 9. 5-STEPS IN TREATING OSTEOPOROSIS 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
    10. 10. USING LOWEST T-SCORE TO FIND 10-YEAR FRACTURE RISK * * L1-4 (minimum 2 valid vertebrae), total hip, trochanter and femoral neck
    11. 11. USING LOWEST T-SCORE TO FIND 10-YEAR FRACTURE RISK - WOMEN Low Risk Moderate Risk High Risk
    12. 12. USING LOWEST T-SCORE TO FIND 10-YEAR FRACTURE RISK
    13. 13. USING LOWEST T-SCORE TO FIND 10-YEAR FRACTURE RISK - MEN Low Risk High Risk Moderate Risk
    14. 14. <ul><li>Absolute fracture risk in 10 years: </li></ul><ul><li>low: <10% </li></ul><ul><li>moderate: 10-20% </li></ul><ul><li>high: >20% </li></ul>CATEGORIZATION BASED ON 10-YEAR FRACTURE RISK
    15. 15. 5-STEPS IN TREATING OSTEOPOROSIS STEP 3 Determine the preliminary fracture risk category by using the lowest T-score from the recommended skeletal sites
    16. 16. 5-STEPS IN TREATING OSTEOPOROSIS STEP 4 Evaluate clinical factors that may move the patient into an even higher fracture risk category
    17. 17. Additional Clinical Factors <ul><li>Certain clinical factors increase fracture risk independent of BMD. </li></ul><ul><li>The most important are: </li></ul><ul><ul><li>Fragility fractures after age 40 (especially vertebral compression fractures) </li></ul></ul><ul><ul><li>Systemic glucocorticoid therapy >3 months duration. </li></ul></ul>
    18. 18. Additional Risk Factors <ul><li>Each factor effectively increases risk categorization to the next level: </li></ul><ul><ul><li>from low risk to moderate risk, or </li></ul></ul><ul><ul><li>from moderate risk to high risk </li></ul></ul><ul><li>When both factors are present the patient should be considered at high risk regardless of the BMD result. </li></ul>
    19. 19. 5-STEPS IN TREATING OSTEOPOROSIS STEP 5 Determine the individual’s final absolute fracture risk category.
    20. 20. <ul><li>52 year-old woman </li></ul>CASE EXAMPLE Lowest T-score –2.7 in total hip BMD done because of menopause (age 49) and family history of osteoporosis
    21. 21. CASE EXAMPLE
    22. 22. High Risk Moderate Risk Low Risk CASE EXAMPLE Low Risk Moderate Risk High Risk
    23. 23. <ul><li>Fracture Risk Category </li></ul>Moderate Risk CASE EXAMPLE
    24. 24. <ul><li>Fracture Risk Category </li></ul>High Risk Moderate Risk If Fragility Fracture History CASE EXAMPLE
    25. 25. CASE EXAMPLE
    26. 27. In Summary The OSC Recommends: <ul><li>Individual’s 10-year absolute fracture risk, rather than BMD alone, be used for fracture risk categorization </li></ul><ul><li>Identify patient’s age/sex from table </li></ul><ul><li>Use lowest T-score to determine preliminary fracture risk </li></ul><ul><li>Evaluate other clinical factors that may move patient to higher risk category </li></ul><ul><li>Determine individual’s absolute fracture risk </li></ul>
    27. 28. Endorsements <ul><li>Canadian Association of Nuclear Medicine </li></ul><ul><li>Canadian Association of Radiologists </li></ul><ul><li>Canadian Rheumatology Association </li></ul><ul><li>International Society of Clinical Densitometry </li></ul><ul><li>Society of Obstetricians and Gynecologists of Canada </li></ul><ul><li>Canadian Society of Endocrinology and Metabolism </li></ul><ul><li>Canadian Orthopedic Association </li></ul><ul><li>College of Family Physicians of Canada </li></ul>

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