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Posts Tagged ‘Treat to Target’

Treat to Target #5 – VFA

February 25, 2018 @ 7:45 pm
posted by Dr Ginther

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

Treat to Target #4 – TBS

February 16, 2018 @ 7:05 pm
posted by Dr Ginther

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

Treat to Target #3 – FRAX

February 9, 2018 @ 5:04 pm
posted by Dr Ginther

Our Target is NO NEW FRACTURES.  The original goal by DXA was a  T-score of -2.4 or better.  But age is a huge factor in actual fracture risk.  The fracture risk of a T-score of -2.5 at age 60 is the same as a T-score of -3.1 at age 50, is the same as a T-score of -1.3 at age 80.

FRAX was developed by WHO and the International Osteoporosis Foundation to take age and other factors into account.  The big 5 risk factors are age, previous fracture, parental hip fracture, smoking, and oral or inhaled corticosteroids.  Rheumatoid arthritis (or diabetes), over 3 doses of alcohol daily, and BMI < 19 or > 35 also count.  Male and Female are different.  Femoral Neck of the hip BMD by DXA is only 30% of the calculation when available.

Treat to Target by FRAX is a “Major Osteoporotic” (wrist, shoulder, hip or clinically noticed spine) Fracture Risk of < 20%.  Alternately a Hip Fracture Risk of < 3.0 is the target.  FRAX identifies a more individualized fracture risk than DXA with or without fragility fracture.

Look up the FRAX tool at http://www.sheffield.ac.uk/FRAX/

FRAX gives different targets than DXA because it takes additional risk factors into account.  And there have been some refinements added.

Jay Ginther, MD

The Bone Health Guidelines are Changing

June 11, 2017 @ 4:58 pm
posted by Dr Ginther

University of Wisconsin hosts biennially the Bare Bones of Osteoporosis Care Symposium.  This year the Wisconsin Bone Club followed the symposium.

Felicia Cosman, MD from Helen Hayes in New York was the guest speaker at both.  She expanded on the new thoughts and guidelines presented at NOF in April.  These were a complete change of approach from just a few years ago.

Treat to Target.  Anabolics first to build bone and then preserve with Antiresorptives.  Reconsider VFA for all first time DXA evaluations.

More detail about these in the weeks to come.

Jay Ginther, MD