Osteoporosis Diagnosis & Monitoring Methods

1. OsteoporosisPart 2 of 3: Diagnosis Ellen Davis-Hall, PhD, PA-C Professor Clare J. Kennedy, MPAS, PA-C Assistant Professor, PA Program SAHP , COM UNMC Omaha, NE. office: 402-559-4738 email: clarekennedy@unmc.edu

2. PROCESS Series of modules and questions Step #1: Power point module with voice overlay Step #2: Case-based question and answer Step # 3: Proceed to additional modules or take a break

3. Objectives • Part 1: Identify risk factors for osteoporosis with an emphasis on modifiable risk factors. • Part 2: Describe the most current methods of, and standards for, diagnosis and monitoring of treatment • Part 3: Describe the available treatment modalities for osteoporosis and their effectiveness

4. Assessment and Screening • Paper/Pencil tests • National Osteoporosis Foundation-NOF self assessment checklist • Osteoporosis Risk Assessment Instrument (ORAI) based on age, weight and estrogen use (Cadarette et al, 2000) • Simple Calculated Osteoporosis Risk Estimation (SCORE)-based on age, race, weight, estrogen use, rheumatoid arthritis and fracture history (Lydick et al, 1998) • Nomogram • Osteoporosis Self-Assessment Tool (OST)-based on age and weight on an easy to read chart (Cadarette et al, 2004)

5. U.S Preventive Services Task Force Screening Recommendations • USPSTF • All women over 65 • Women 60-64 if “at risk” “At Risk”: • Best predictor = low body weight • Others: early menopause, white/Asian, sedentary, smoker, alcohol abuse, caffeine use, low calcium and vitamin D intake, family history, primary hyperparathyroid, hyperthytroid, corticosteroids, phenytoin Cadarette SM, Jaglal SB, Murray T, et al. Evaluation of decision rules for referring women for bone densitometry by dual-energy x-ray absorptiometry. JAMA 2001;286(1):57-63.

6. National Osteoporosis Foundation • Screen if these risk factors are present: • All women 65 and older • Postmenopausal women under age 65 with: • Family history of osteoporosis • Past history of low trauma fracture if over 45 • Cigarette smoking • Low body weight (under 127 #)

7. Other Screening Considerations • Hyperthyroidism • Hyperparthyroidism • X-ray evidence of low bone mass • Vitamin D deficiency (osteo-malacia) • Rheumatoid arthritis • Medications known to cause bone loss • Diseases that cause poor intestinal absorption • Long term menstrual irregularities

8. Tools for Diagnosing and Monitoring Response to Treatment • Thorough H&PE • Lab • X-rays • Bone densiometry • US • Bone markers

9. History and Physical Assessment • Assess risk factors • Identify a history of falls/fractures • Weight, height, general health • Spine/bony structure assessment • Gait and balance

10. Laboratory and X-Ray Studies • Lab: • CBC, serum calcium, phosphorus, alkaline phosphatase, renal function, TSH. • Possible additional lab: 24 hours urine for creatinine and calcium, parathyroid hormone assay, LFTs, serum testosterone, cortisol assays, protein electrophoresis • X-Ray: • Useful when fractures are suspected, not effective for screening

11. Dual Energy X-ray Absorptiometry (DEXA) • The gold standard for diagnosis and monitoring • Non-invasive • Low x-ray exposure • High sensitivity and specificity • Limitations: • Osteoarthritis, aortic calcification, or compression fracture may yield erroneous values in the spine. Use proximal femur measurements.

12. DEXA Interpretation Diagnostic Criteria for Osteoporosis in Post-menopausal Women CategoryDefinition by BMD Score NormalBMD <1 SD below mean value for young adult white females OsteopeniaBMD 1-2.5 SD below mean value for young adult white females OsteoporosisBMD > 2.5 SD below the mean value for young adult white females

13. Other Tools for Osteoporosis Evaluation • Quantitative ultrasound • Heel, finger, tibia, patellar measurements • Inexpensive • No radiation • Less sensitive than DEXA • Bone markers • Measure osteoblastic or osteoclastic activity • Research instrument

14. Monitoring and Evaluating Treatment of Osteopenia/Osteoporosis • Follow-up DEXAs only when change might result • Follow-up DEXA for patients with normal or minimally low BMD every 3-5 years • Patients on medication-repeat DEXA 18 to 24 months after therapy was begun

15. Summary of Part 2: Diagnosis and Monitoring • There are various screening methods • paper and pencil testing • History and physical risk assessment • Formal laboratory/x-ray studies • DEXA is the gold standard for diagnosis and monitoring of both osteopenia and osteoporosis

16. The End of Module Two on Osteoporosis References • Bone Health and Osteoporosis: A Report of the Surgeon General, USDHHS, issued October 14, 2004 www.surgeongeneral.gov/library/bonehealth • Cadarette et al, Development and validation of the osteoporosis risk assessment instrument to facilitate selection of women for bone densiometry. CMAJ, 2000, May 2,162(9):1289-94 • Cadarette et al, The validity of decision rules for selecting women with primary osteoporosis for BMD testing. Osteoporosis Int, 2004, Jan 17 • Lydick et al, Development and validation of a simple questionnaire to facilitate identification of women likely to have low bone density. Am J Manag Care, 1998, Jan 4(1):37-48 • National Osteoporosis Foundation. America’s bone health: The state of osteoporosis and low bone mass in our nation. Washington (DC): National Osteoporosis Foundation; 2002 • US Preventive Services Task Force. Screening for osteoporosis in postmenopausal; women: Recommendations and rationale. Ann Intern Med, 2002, Sept 17; 137(6):526-8

17. Post-test A 65 year old woman returns to your office after DEXA testing to discuss her results. Noting that her total BMD is -2.2, you inform her she has: • Normal bone mass • Osteopenia • Osteoporosis • Severe osteoporosis

18. Correct Answer: Osteopenia Feedback: Osteopenia.Bone mass is considered to be in the normal range if < -1.0. Results falling between -1.0 and -2.5 diagnose osteopenia, and results > -2.5 make the diagnosis for osteoporosis. A patient in the osteoporotic range who has also had a fracture can be said to have severe osteoporosis. End