BMD in Family Prac ce Marc Freeman, MD FRCPC Physician Lead, Nuclear Medicine Assistant Professor Department of Medical Imaging University of Toronto marc.freeman@trilliumhealthpartners.ca 1
Disclosure of Commercial Support This program has received no financial or in- kind support. Poten al for conflict(s) of interest: Not applicable
Faculty/Presenter Disclosure Faculty: Marc Freeman Rela onships with commercial interests: Other: Principal in Credit Valley Imaging Associates, MyHealth Centre and Radiology Now.
Mi ga ng Poten al Bias Evidence- based content
Game On 2015-2016 One 15 min period of Pearls Radia on Technical Pa ent Report Risk Modifiers Appropriateness/ Follow- up 5
BMD To diagnosis osteoporosis To determine # risk To monitor therapy 6
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Pearl # 1 Doses from DXA facili es to pa ents, staff, and members of the public are normally not a concern 8
Scan #1 Scan #2 Scan #2 9
Pearl # 2 BMD values from different manufacturers are not comparable BMD values from different machines of the same manufacturer are not comparable Pa ents should not be shi ed to different units in follow- up exams 10
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Scan #1 Scan #2 12
Pearls # 3 & 4 Height Documenta on important 40% of women with osteoporo c # have a history Mul ple #s > risk Vertebra & hip #s > risk Weight Significant changes in body weight have unpredictable effects on bone density and affect serial measurements >10% introduce ar facts necessitate new baseline Prospec ve Height Loss 1 >2.0 cm over 3 years Sn: 35.5% Sp: 93.6% 1. Siminoski et al. Osteoporos Int 2005;16:403-410. 13
Diagnos c Category 50+ T- score Lowest from lumbar spine, femoral neck or total hip 18-49 Z- score Lowest from lumbar spine, femoral neck or total hip 14
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Fracture Risk Category T- score of femoral neck 17
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Pearl # 5 Fracture Risk Reflects the theore cal risk of a pa ent who is treatment- naïve Does not reflect any reduc on in risk associated with therapy 20
History used for risk determina on Fragility fracture status Glucocor coid use 21
Fragility Fracture One that occurs spontaneously, or from a fall from a standing height Risk of experiencing another fracture in the year following a hip fracture*: 5-10% 1,2 Risk of experiencing another fracture in the year following a vertebral fracture + : 20% 3 Bone ac ve drug therapy lowers risk by 30-70% 3 * in men and women + in postmenopausal women 1. Papaioannou et al. JOGC 2000;22(8):591-597. 2. Colon-Emeric et al. Osteoporos Int 2003;14:879-893 3. Lindsay R et al. JAMA 2001; 285:320-323 22
Pearls # 6 & 7 Fragility Fractures Age > 40 Spine (>25%), hip, proximal humerus, forearm Other types of fractures have weaker rela onships to osteoporosis but may be regarded as fragility fractures if the history suggests that the fracture occurred with a degree of trauma than would not normally be expected to lead to a broken bone. 3 Not Fragility Fractures 1 Not spine <25% 2 Not trauma c (moderate- high energy injuries) Not stress (repe ve) Not rib Not pathologic Not atypical femoral fractures 1. Burrell, CBMD. October 25, 2014. 2. Lentle et al, CARJ 2007;58:27-36. 3. Siminoski et al. CARJ 2013;64:281-294. 23
Pearl # 8 Steroids >/- 7.5 mg/day for 3 months cumula ve in past year (prednisone equivalent) 24
Burrell, CBMD. October 25, 2014. 25
Pearl # 8 Cannot Establish Fracture Risk Age < 50 Neither hip is valid Metabolic bone disease 26
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Indica ons - Baseline 28
Follow- up Low: 5-10 years Medium: 1-3 years High: 1-2 years 2006/2007 Normal baseline & No RF: 3-5 years Subsequent test (RBL<1%): 7-10 years If 1 or more risk factors - T<1.0, RF, RBL > 1% or receiving OP treatment: at discre on of physician (1-2 years) Follow up BMD test when there is a significant change Intervals for serial tes ng should be based on clinical status 1 year a er ini a on or change of therapy Longer interval once therapeu c effect Test more frequently in condi ons associated with rapid bone loss 29
Schedule of Benefits, May 1, 2014. 30
Pearl #9 High Risk OHIP does not = High Risk OC High Risk OHIP At risk for accelerated bone loss Osteopenia (i.e. low bone mass) & Osteoporosis Bone loss in excess of 1% High Risk OHIP can have a funded study every 12 months Low Risk OHIP means a pa ent not at high risk ; second scan at 36 months, third & + at 60 months 31
Summary Very low effec ve dose = one year of background radia on Perform serial scans at same facility PHL 2.0 cm over 3 years get an lumbar xray >10% BW serial scans not comparable Not a fragility fracture: age < 40, <25% spine, stress, rib, trauma c, pathologic Conven onal criteria for recent prolonged steroid use: >/= 7.5mg/day for 3 months cumula ve 12 months (prednisone equivalent) OHIP defini on of low/high risk is much different from Osteoporosis Canada 32