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Gani LU, Sritara C, Blank RD, Chen W, Gilmour J, Dhaliwal R, Gill R. Follow-up Bone Mineral Density Testing: 2023 Official Positions of the International Society for Clinical Densitometry. J Clin Densitom 2024; 27:101440. [PMID: 38007875 DOI: 10.1016/j.jocd.2023.101440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
Dual-energy X-ray absorptiometry (DXA) is the gold standard method for measuring bone mineral density (BMD) which is most strongly associated with fracture risk. BMD is therefore the basis for the World Health Organization's densitometric definition of osteoporosis. The International Society for Clinical Densitometry (ISCD) promotes best densitometry practices and its official positions reflect critical review of current evidence by domain experts. This document reports new official positions regarding follow-up DXA examinations based on a systematic review of literature published through December 2022. Adoption of official positions requires consensus agreement from an expert panel following a modified RAND protocol. Unless explicitly altered by the new position statements, prior ISCD official positions remain in force. This update reflects increased consideration of the clinical context prompting repeat examination. Follow-up DXA should be performed with pre-defined objectives when the results would have an impact on patient management. Testing intervals should be individualized according to the patient's age, sex, fracture risk and treatment history. Incident fractures and therapeutic approach are key considerations. Appropriately ordered and interpreted follow-up DXA examinations support diagnostic and therapeutic decision making, thereby contributing to excellent clinical care. Future research should address the complementary roles of clinical findings, imaging and laboratory testing to guide management.
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Affiliation(s)
- Linsey U Gani
- Department of Endocrinology, Changi General Hospital, Singapore.
| | - Chanika Sritara
- Nuclear Medicine Division, Department of Diagnostic and Therapeutic Radiology. Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - WeiWen Chen
- Department of Endocrinology, St Vincent's Hospital Sydney, Australia
| | - Julia Gilmour
- Division of Endocrinology, St Michael's Hospital, Department of Medicine, University of Toronto
| | - Ruban Dhaliwal
- Endocrine Unit, Massachusetts General Hospital and Harvard Medical School
| | - Ranjodh Gill
- Department of Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia
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Thériault G, Limburg H, Klarenbach S, Reynolds DL, Riva JJ, Thombs BD, Tessier LA, Grad R, Wilson BJ. Recommendations on screening for primary prevention of fragility fractures. CMAJ 2023; 195:E639-E649. [PMID: 37156553 PMCID: PMC10166624 DOI: 10.1503/cmaj.221219] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Fragility fractures are a major health concern for older adults and can result in disability, admission to hospital and long-term care, and reduced quality of life. This Canadian Task Force on Preventive Health Care (task force) guideline provides evidence-based recommendations on screening to prevent fragility fractures in community-dwelling individuals aged 40 years and older who are not currently on preventive pharmacotherapy. METHODS We commissioned systematic reviews on benefits and harms of screening, predictive accuracy of risk assessment tools, patient acceptability and benefits of treatment. We analyzed treatment harms via a rapid overview of reviews. We further examined patient values and preferences via focus groups and engaged stakeholders at key points throughout the project. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to determine the certainty of evidence for each outcome and strength of recommendations, and adhered to Appraisal of Guidelines for Research and Evaluation (AGREE), Guidelines International Network and Guidance for Reporting Involvement of Patients and the Public (GRIPP-2) reporting guidance. RECOMMENDATIONS We recommend "risk assessment-first" screening for prevention of fragility fractures in females aged 65 years and older, with initial application of the Canadian clinical Fracture Risk Assessment Tool (FRAX) without bone mineral density (BMD). The FRAX result should be used to facilitate shared decision-making about the possible benefits and harms of preventive pharmacotherapy. After this discussion, if preventive pharmacotherapy is being considered, clinicians should request BMD measurement using dual-energy x-ray absorptiometry (DXA) of the femoral neck, and re-estimate fracture risk by adding the BMD T-score into FRAX (conditional recommendation, low-certainty evidence). We recommend against screening females aged 40-64 years and males aged 40 years and older (strong recommendation, very low-certainty evidence). These recommendations apply to community-dwelling individuals who are not currently on pharmacotherapy to prevent fragility fractures. INTERPRETATION Risk assessment-first screening for females aged 65 years and older facilitates shared decision-making and allows patients to consider preventive pharmacotherapy within their individual risk context (before BMD). Recommendations against screening males and younger females emphasize the importance of good clinical practice, where clinicians are alert to changes in health that may indicate the patient has experienced or is at higher risk of fragility fracture.
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Affiliation(s)
- Guylène Thériault
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Heather Limburg
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Scott Klarenbach
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Donna L Reynolds
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - John J Riva
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Brett D Thombs
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Laure A Tessier
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Roland Grad
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
| | - Brenda J Wilson
- Departments of Family Medicine (Theriault, Grad) and Psychiatry (Thombs), McGill University, Montréal, Que.; Public Health Agency of Canada (Limburg, Tessier), Ottawa, Ont.; Department of Medicine (Klarenbach), University of Alberta, Edmonton, Alta.; Department of Family and Community Medicine (Reynolds), University of Toronto, Toronto, Ont.; Department of Family Medicine (Riva), McMaster University, Hamilton, Ont.; Department of Medicine (Wilson), Memorial University, St. John's, NL
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Kline GA, Morin SN, Lix LM, Leslie WD. Apparent "Rapid Loss" After Short-Interval Bone Density Testing in Menopausal Women Is Usually a Measurement Artifact. J Clin Endocrinol Metab 2022; 107:1662-1666. [PMID: 35134963 DOI: 10.1210/clinem/dgac051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Medication may be considered when bone mineral density (BMD) loss is reported as "excessive." OBJECTIVE We hypothesized that the rate of BMD change between 2 serial tests demonstrates higher random variability at shorter vs longer intervals, misclassifying some women as "rapid losers." METHODS This retrospective observational cohort study in Manitoba, Canada included women aged > 55 years without osteoporosis medications or glucocorticoids. Using paired baseline (1998-2016) and repeat (2001-2018) BMD measurements, we estimated the distribution of annualized change (first to second BMD) at spine, hip, and femoral neck stratified by testing interval (2-2.9, 3-3.9,...9-9.9, ≥ 10.0 years). "Rapid annual bone loss" was defined as exceeding the 95th percentile for decreases from all measurement pairs. Odds ratios (OR) for rapid loss were estimated using regression models adjusted for age and clinical covariates. RESULTS From 7126 paired BMD measurements, mean annualized change was constant yet standard deviations in BMD change were > 2-fold greater with intervals of 2 to 2.9 years vs ≥ 10 years(P < 0.001). "Rapid annual loss" was seen in ~10% of short-interval tests vs < 1% of long-interval tests. ORs for "rapid loss" progressively declined with increasing testing interval (spine 15.3 [4.8-48.9], total hip 9.3 [4.4-19.5], femoral neck 18.7 [6.8-51.3] for a 2- to 2.9-year testing interval; referent ≥ 10 years). CONCLUSION There is a wider apparent range in annualized BMD loss with short-interval testing which greatly attenuates over longer intervals. BMD reports of "rapid loss" across shorter testing intervals likely reflect an artifact of BMD measurement error and should not be used as an indication for antifracture medication initiation.
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Affiliation(s)
- Gregory A Kline
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, T2T 5C7, Canada
| | - Suzanne N Morin
- Department of Medicine, Faculty of Medicine, McGill University, Montreal, H3A 1A1, Canada
| | - Lisa M Lix
- Department of Community Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, R3E 0W2, Canada
| | - William D Leslie
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, R3E 0W2, Canada
- Department of Radiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, R3E 0W2, Canada
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Leslie WD, Morin SN, Lix LM, Martineau P, Bryanton M, McCloskey EV, Johansson H, Harvey NC, Kanis JA. Reassessment Intervals for Transition From Low to High Fracture Risk Among Adults Older Than 50 Years. JAMA Netw Open 2020; 3:e1918954. [PMID: 31922559 PMCID: PMC6991318 DOI: 10.1001/jamanetworkopen.2019.18954] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Fracture risk scores are used to identify individuals at high risk of major osteoporotic fracture or hip fracture for antiosteoporosis treatment. For those not meeting treatment thresholds at baseline, the optimal interval for reassessing fracture risk is uncertain. OBJECTIVE To examine reassessment intervals for transition from low to high fracture risk under guidelines-defined treatment thresholds. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included persons aged 50 years or older with fracture risk below treatment thresholds at baseline who had fracture risk reassessed at least 1 year later. Data were obtained from a population-based bone mineral density registry (baseline assessment during 1996-2015; reassessment to 2016) in the Province of Manitoba, Canada. Primary analysis was performed from May to June 2019. Analysis for the revision was performed in October 2019. MAIN OUTCOMES AND MEASURES The primary outcome was time to transition from low (below the treatment threshold) to high fracture risk (treatment-qualifying risk score using osteoporosis clinical practice guidelines strategies for Canada, the United States, and the United Kingdom). RESULTS The study population consisted of 10 564 individuals (94.1% women; mean [SD] age at baseline, 63.2 [8.2] years). At the time of reassessment (a mean [SD] interval of 5.2 [2.9] years between initial and subsequent fracture risk assessment), 690 (6.6%) had reached the fixed major osteoporotic fracture treatment threshold of 20%, 1546 (16.2%) had reached the fixed hip treatment threshold of 3%, and 932 (9.4%) had reached the age-dependent major osteoporotic fracture treatment threshold. Among those below 25% of the treatment threshold at baseline for each guideline, few (0%-3.0%) reached guidelines-defined high fracture risk at follow-up. In contrast, among those at the upper end of the scale for each guideline (75%-99% of the treatment threshold at baseline), 30.6% to 74.4% reached guidelines-defined high fracture risk. An increased number of clinical risk factors was associated with increased likelihood of reaching guidelines-defined high fracture risk (range for 3 guidelines, 17.1%-28.2%) compared with unchanged or decreased clinical risk factors (range for 3 guidelines, 3.3%-12.8%) (P < .001). Estimated time for 10% of the population to reach treatment-qualifying high fracture risk ranged from fewer than 3 years to more than 15 years. CONCLUSIONS AND RELEVANCE The findings suggest that baseline fracture risk (as a fraction of the treatment threshold) and change in clinical risk factors can identify individuals with low and high probability of guidelines-defined high fracture risk during follow-up, thereby potentially helping to inform the reassessment interval.
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Affiliation(s)
- William D. Leslie
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Suzanne N. Morin
- Division of General Internal Medicine, McGill University, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Lisa M. Lix
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Patrick Martineau
- Section of Nuclear Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Harvard Medical School, Boston, Massachusetts
| | - Mark Bryanton
- Section of Nuclear Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eugene V. McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, United Kingdom
| | - Helena Johansson
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, United Kingdom
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Nicholas C. Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, United Kingdom
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - John A. Kanis
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, United Kingdom
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
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Abstract
The substantial increase in the burden of non-communicable diseases in general and osteoporosis in particular, necessitates the establishment of efficient and targeted diagnosis and treatment strategies. This chapter reviews and compares different tools for osteoporosis screening and diagnosis; it also provides an overview of different treatment guidelines adopted by countries worldwide. While access to dual-energy X-ray absorptiometry to measure bone mineral density (BMD) is limited in most areas in the world, the introduction of risk calculators that combine risk factors, with or without BMD, have resulted in a paradigm shift in osteoporosis screening and management. To-date, forty eight risk assessment tools that allow risk stratification of patients are available, however only few are externally validated and tested in a population-based setting. These include Osteoporosis Self-Assessment Tool; Osteoporosis Risk Assessment Instrument; Simple Calculated Osteoporosis Risk Estimation; Canadian Association of Radiologists and Osteoporosis Canada calculator; Fracture Risk Assessment Calculator (FRAX); Garvan; and QFracture. These tools vary in the number of risk factors incorporated. We present a detailed analysis of the development, characteristics, validation, performance, advantages and limitations of these tools. The World Health Organization proposes a dual-energy X-ray absorptiometry-BMD T-score ≤ -2.5 as an operational diagnostic threshold for osteoporosis, and many countries have also adopted this cut-off as an intervention threshold in their treatment guidelines. With the introduction of the new fracture assessment calculators, many countries chose to include fracture risk as one of the major criteria to initiate osteoporosis treatment. Of the 52 national guidelines identified in 36 countries, 30 included FRAX derived risk in their intervention threshold and 22 were non-FRAX based. No universal tool or guideline approach will address the needs of all countries worldwide. Osteoporosis screening and management guidelines are best tailored according to the needs and resources of individual counties. While few countries have succeeded in generating valuable epidemiological data on osteoporotic fractures, to validate their risk calculators and base their guidelines, many have yet to find the resources to assess variations and secular trends in fractures, the performance of various calculators, and ultimately adopt the most convenient care pathway algorithms.
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Affiliation(s)
- Ghada El-Hajj Fuleihan
- Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, Division of Endocrinology and Metabolism, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Marlene Chakhtoura
- Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, Division of Endocrinology and Metabolism, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jane A Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nariman Chamoun
- Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, Division of Endocrinology and Metabolism, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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