Posts Tagged ‘DXA’
National Bone Health treatment goals are changing for those patients with high fracture risk. Simply preserving bones already at a too high fracture risk never made much sense to this former orthopedic surgeon. Now the national leadership is stressing the need to lower fracture risk first, then preserve bones at a lower level of fracture risk.
We now have 3 anabolic medications which substantially lower fracture risk by increasing the thickness and strength of bone structure: Teriparatide (Forteo), Abaloparitide (Tymlos), and Romosozumab (Evenity). They all decrease fracture risk substantially more than the antiresorptive (preserving) medications alone. The difference in fracture risk grows for up to 5 years. After that the difference in fracture risk between anabolic meds followed by preserving meds vs. preserving meds alone remains the same.
Calcium can take up to 3 additional years to collect in newly formed bone matrix. DXA shows calcium in bone (Bone Mineral Density). Much of the increased BMD can only be seen on DXA after the anabolic med is completed and the antiresorptive med is started.
All of the anabolic medications must be followed by antiresorptive medication to preserve the gains made by the anabolic. No medication to grow or preserve bone can work without adequate nutrition in the form of absorbable calcium, vitamin D3, protein and other vitamins and minerals.
Jay Ginther, MD
Recently I wrote about our participation in a clinical trial offering the anabolic Tymlos (Abaloparatide) to men. Now we have been approved for participation in another Tymlos (Abaloparatide) trial – this one for women. Currently Tymlos is available to women as a daily shot. The new delivery system is a patch applied to the skin for 5 minutes daily. That is far more convenient than a shot.
The FDA compliant trial is being run by the Northeast Iowa Family Practice Center. They have years of experience with clinical trials. Clinical trials always have strict inclusion and exclusion criteria requiring extensive screening, interviews and multiple testings. All screening is free to the participant. If you are accepted into the trial, all treatment is also at no charge.
All participants will receive the FDA approved anabolic (increases bone matrix) medication Tymlos (Abaloparatide). Participants are randomized to the standard injection or the new patch.
Our participation in the study is that Bone Health will be doing all screening and quarterly study DXAs and ADI (Advanced Diagnostic Imaging of Iowa) will be doing the spine x-rays. We are also screening our own patients for potential to be study participants.
Remember that anabolic medications Forteo (Teriparatide), Tymlos (Abaloparatide), and Evenity (Romosozumab), primarily stimulate new bone formation. Antiresorptives Fosamax (Alendronate), Actonel/Atelvia (Risendronate), Boniva (Ibandronate), Reclast (Zolendronate), Evista (Raloxifene), and Prolia (Denosumab), primarily preserve bone.
Of course, all medications require proper nutrition to work well.
Jay Ginther, MD
Treat to Target of NO NEW FRACTURES. How do we find that target? DXA >-2.5 is a start. Fragility fractures increase new fracture risk. FRAX adds many more risk factors to the calculation and TBS refines FRAX.
Vertebral Fracture Assessment (VFA) looks at the spine from the side and independently identifies additional fracture risk. This can be done on a DXA machine or by x-ray. A single vertebral compression fracture of 25% or more pre-empts DXA, BMD, and FRAX in diagnosing Clinical Osteoporosis and recommending treatment.
VFA should be done because the majority of vertebral compression fractures are first noticed by x-ray or DXA VFA imaging. If you do not personally view the images, be sure the radiologist specifically checked for vertebral deformities as described by Genant.
I recently published my retrospective review of 1259 sequential first time VFA patients in Endocrine Practice 2017:23:1375-8.
VFA identified many patients not identified as high fracture risk (Clinical Osteoporosis) by DXA or fragility fracture or height loss or kyphosis or FRAX.
We should consider including VFA in every first time Complete Bone Health Evaluation.
And how should we treat? Next time…
Jay Ginther, MD
Our goal is NO NEW FRACTURES. Cancellous (spongy, like the ends of the drumstick) bone should be a strong latticework of struts called trabeculi. Clinical Osteoporosis, an increased fracture risk, occurs when some of the struts disappear.
Trabecular Bone Score (TBS) evaluates the spongy bone in the DXA images of the vertebrae (spine) looking for irregularities. When TBS finds uneven bone mineral density within the spine DXA, that indicates a higher fracture risk, regardless of the total BMD.
Adding the TBS feature to a DXA machine allows the quality of bone in the spine to influence the FRAX score, just like the BMD in the femoral neck part of the hip influences the FRAX score. Adding TBS detects more patients at high fracture risk who should be treated to avoid fractures.
Diabetes increases a person’s fracture risk for any given DXA BMD or T-score. Controlled diabetes adds about the same risk as rheumatoid arthritis, so we usually check that box in FRAX. Uncontrolled diabetes is more serious requiring further adjustment to FRAX.
FRAX is pre-empted by a hip fracture. “Do not pass GO, do not collect $200, start a pharmaceutical” Vertebral (spine) Fracture is the same, but the majority of spine fractures are not noticed clinically. “Morphometric” (first noticed on x-ray) vertebral fractures count, but how to find them?
VFA next time
Jay Ginther, MD