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

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 2002 Definitions: BMD Results

Status 1, 2 T-score
Normal +2.5 to 1.0, inclusive
Osteopenia Between 1.0 and 2.5
Osteoporosis 2.5
Severe osteoporosis 2.5 + fragility fracture
1. Kanis JA, et al. J Bone Miner Res 1994;9:1137-1141.
2. WHO, Geneva 1994. www.osteoporosis.ca
 2002 OSC Guidelines

Who Should Be Treated for Osteoporosis?

Personal history Non-traumatic Clinical risk Low

Long-term vertebral
glucocorticoid of fragility fracture compression factors DXA BMD
therapy after age 40 deformities (1 major or 2 minor) (T-score <2.5)

Start AND
bisphosphonate
therapy Low DXA BMD (T-score <1.5)

Obtain Consider
DXA BMD therapy
for follow-up

Repeat DXA BMD

after 1or 2 years

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 WHATS WRONG WITH
T-SCORES?
Advantages Disadvantages
Unitless Depends on site measured
Basis for the majority of Depends on technology
osteoporosis guidelines
Depends on reference
Simplicity databasepopulation mean
and standard deviation
Only includes BMD
information and not additional
risk factors
Adapted from Faulkner K. Osteoporos Int 2005;16(4):347-52.
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 BMD PREDICTS FRACTURES

Fracture
Fracture Risk
Risk
vs.
vs. BMD
BMD
At
At Different
Different Ages
Ages

Hui et al. J Clin Invest 1988; 81:1804-9 www.osteoporosis.ca

Risk of Fractures Over 10 Years in Women

AGE T-Score T-Score

= -1.0 = -2.5
50 6% 11 %

60 8% 16 %

70 12 % 23 %

80 13 % 26 %

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 Proposed Change

Previous OSC guidelines advised intervention

based on WHO category as a marker of relative
fracture risk.

Now propose that an individuals 10-year absolute

fracture risk, rather than BMD alone, be used for
fracture risk categorization
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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 individuals risk of osteoporotic fracture

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 5-STEPS IN
TREATING OSTEOPOROSIS
STEPS 1 and 2

Begin with the table appropriate for

the patients sex
Identify the row that is closest to
the patient's age

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 USING LOWEST T-SCORE TO FIND 10-YEAR
FRACTURE RISK*

* L1-4 (minimum 2 valid vertebrae), total hip, trochanter and femoral neck
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USING LOWEST T-SCORE TO FIND 10-YEAR FRACTURE RISK
- WOMEN

WOMEN
0.0
-0.5
Low Risk
LOWEST T-Score

-1.0
-1.5 Moderate Risk
-2.0
-2.5
-3.0
-3.5
High Risk
-4.0
-4.5
50 55 60 65 70 75 80 85
AGE (years)
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USING LOWEST T-SCORE TO FIND 10-YEAR FRACTURE RISK

MEN
10-YEAR RISK
AGE LOW MODERATE HIGH
<10% 10 to 20% >20%
50 >-3.4 <=-3.4 ---
55 >-3.1 <=-3.1 ---
60 >-3.0 <=-3.0 ---
65 >-2.7 <=-2.7 ---
70 >-2.1 -2.1 to -3.9 <-3.9
75 >-1.5 -1.5 to -2.9 <-3.2
80 >-1.2 -1.2 to -3.0 <-3.0
85 >-1.3 -1.3 to -3.3 <-3.3

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USING LOWEST T-SCORE TO FIND 10-YEAR FRACTURE RISK
- MEN

MEN
0.0
-0.5
-1.0
-1.5
Low Risk
LOWESTT-Score

-2.0
-2.5
Moderate Risk
-3.0
-3.5
-4.0 High Risk
-4.5
50 55 60 65 70 75 80 85
AGE (years)
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CATEGORIZATION BASED ON 10-YEAR
FRACTURE RISK

Absolute fracture risk in 10 years:

low: <10%
moderate: 10-20%
high: >20%

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 5-STEPS IN
TREATING OSTEOPOROSIS

STEP 3

Determine the preliminary fracture risk

category by using the lowest T-score
from the recommended skeletal sites

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 5-STEPS IN
TREATING OSTEOPOROSIS

STEP 4

Evaluate clinical factors that may move

the patient into an even higher fracture
risk category

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 Additional Clinical Factors

Certain clinical factors increase fracture

risk independent of BMD.
The most important are:
Fragility fractures after age 40 (especially
vertebral compression fractures)
Systemic glucocorticoid therapy >3 months
duration.
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 Additional Risk Factors

Each factor effectively increases 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 at high
risk regardless of the BMD result.

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 5-STEPS IN
TREATING OSTEOPOROSIS

STEP 5

Determine the individuals final

absolute fracture risk category.

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 CASE EXAMPLE

52 year-old woman
BMD done because of menopause (age
49) and family history of osteoporosis

Lowest T-score 2.7 in total hip

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 CASE EXAMPLE

WOMEN
10-YEAR RISK
AGE LOW MODERATE HIGH
<10% 10 to 20% >20%
50 >-2.3 -2.2 to -3.9 <-3.9
55 >-1.9 1.9 to -3.4 <-3.4
60 >-1.4 -1.4 to -3.0 <-3.0
65 >-1.0 -1.0 to -2.6 <-2.6
70 >-0.8 -0.8 to -2.2 <-2.2
75 >-0.7 -0.7 to -2.1 <-2.1
80 >-0.6 -0.6 to -2.0 <-2.0
85 >-0.7 -0.7 to -2.2 <-2.2

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 CASE EXAMPLE

WOMEN
0.0
-0.5
Low Risk
-1.0
LOWEST T-Score

-1.5 Low Risk Moderate Risk

-2.0
Moderate Risk
-2.5
-3.0
-3.5
High Risk
-4.0 High Risk
-4.5
50 55 60 65 70 75 80 85
AGE (years)

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 CASE EXAMPLE

Moderate Risk Category

Fracture Risk

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 CASE EXAMPLE

Moderate Risk Category

Fracture Risk

If Fragility Fracture History

High Risk

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 CASE EXAMPLE

WOMEN
10-YEAR RISK
AGE LOW MODERATE HIGH
<10% 10 to 20% >20%
50 >-2.3 -2.2 to -3.9 <-3.9
55 >-1.9 1.9 to -3.4 <-3.4
60 >-1.4 -1.4 to -3.0 <-3.0
65 >-1.0 -1.0 to -2.6 <-2.6
70 >-0.8 -0.8 to -2.2 <-2.2
75 >-0.7 -0.7 to -2.1 <-2.1
80 >-0.6 -0.6 to -2.0 <-2.0
85 >-0.7 -0.7 to -2.2 <-2.2

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 In Summary
The OSC Recommends:

Individuals 10-year absolute fracture risk, rather

than BMD alone, be used for fracture risk
categorization
Identify patients 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 individuals absolute fracture risk www.osteoporosis.ca
 Endorsements

Canadian Association of Nuclear Medicine

Canadian Association of Radiologists
Canadian Rheumatology Association
International Society of Clinical Densitometry
Society of Obstetricians and Gynecologists of Canada
Canadian Society of Endocrinology and Metabolism
Canadian Orthopedic Association
College of Family Physicians of Canada

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