A Look at Osteoporosis Screening Guidelines

1. A Look at Osteoporosis Screening Guidelines Cynthia Phelan PGY 1 2003 08 07

2. Osteoporosis • Systemic disease • Low bone mass • Micro-architectural deterioration of bone tissue • Increased fragility • Increase risk of fracture • WHO – T-score lower than -2.5

3. Societal Impact • 1 in 4 women • 1 in 8 men • Cause of over 70% of fractures in people over the age of 45 • High cost to society for treatment of fractures and associated morbidity

4. Important for all patients! • Prevention efforts must begin early • Peak bone mass attained by the third decade • Encourage exercise – resistance and impact • Nutrition important • Encourage Ca (1000 -1500mg) and Vit D (400 - 800 IU) supplementation in those who have poor dietary intake

5. Who to screen? • Screen all who have one of … • Age >65yrs • History of fragility fracture after age 40 • Osteoporosis in a first degree relative • Thin build….BMI < 20 or wt < 57.8Kg • Early menopause (<45yrs) • Chronic hypogonadism • Chronic malnutrition / malabsorption • Chemotherapy (if long term survival expected)

6. Who to screen? • Screen all who have one of … • Glucocorticoid therapy • 7.5mg of prednisone per day for more than 3 months • Cushing's Syndrome • Prolonged use of anticonvulsants (>10yrs) • Documented loss of height • Development of kyphosis after menopause • Primary hyperparathyroidism

7. Who to screen?? • Screen patients who have two or more of.. • Current smoking • History of hyperthyroidism • Low calcium intake • Alcoholism • Excessive caffeine intake

9. Who to screen?? • 4 Key Risk Factors have been found to be most predictive of potential fracture related to osteoporosis • Low Bone Mineral Density • Prior Fragility Fracture • Age >65 • Family History of Osteoporosis

10. Screening Tools • DEXA (Dual energy X-ray absorptiometry) • Single most predictive test for identification of patients at risk • Gold standard • Useful for assessing patient current BMD as compared to standard and for watching changes in pts BMD over time • Operator error may alter results • Results may also be skewed by compression fractures

11. Screening Tools • Peripheral Bone Density Testing • Measured by DEXA or US at several sites (radius, phalanx, calcaneus) • Used more often in under serviced areas • Useful for predicting fracture risk • Not good for following pts thus not a recommended screening tool to date

12. Screening Tools • Blood and Urine Studies of bone turnover markers (CBC, Ca, Alk Phos, Creat) • Useful to investigate secondary causes • Individual patients show large variation in test results from one day to the next • Cannot readily be used to identify patients at risk • Not recommended as screening tools or as tools to monitor effect of therapy

13. Diagnosis • Recommendations • Patients at increased risk and those over age 65 should have BMD done via DEXA • Peripheral US or DEXA should not be used for following patients • Additional studies are required before biochemical markers become a useful tool in screening and surveillance of osteoporosis

14. Interpretation of Results

15. When to start treatment • Therapy used to prevent bone deterioration and reduce fractures • Treating women with T-score less -2 or a T-score less than -1.5 with risk factors has been deemed cost effective. • Clinical decision making must be made on a patient to patient basis.

16. Take Home Points • Consider risk factors in all patients • Screen patients who are at risk with DEXA • Don’t neglect elderly patients with multiple medical problems – they may benefit greatly from therapy (even if they are resistant to additional medications) • Consider Rx in all patients with t-score less than -1.5 (+risk factors) or -2.

17. Take Home Points • Prevention, prevention, prevention Start very early! • Yuen CK et al. Canadian Consensus on Menopause and Osteoporosis. Osteoporosis. Journal of Obstetrics and Gynecology of Canada. 2002; 24(10): 35-44. • Brown JP et al. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ 2002; 167(10): S1-36.