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bone mineral density (BMD)

Also see screening for osteoporosis. Indications: 1) all women > 65 years of age & all men > 70 years of age [1] - USPSTF concludes not enough evidence to determine whether routine screening is beneficial or harmful for men [6] 2) postmenopausal women < 65 & men < 70 years of age with one additional risk factor for osteoporosis 3) rule out low-trauma fracture 4) radiographic findings suggestive of osteoporosis or vertebral deformity 5) height loss, kyphosis: - > 2 cm (documented), > 4 cm (historical) - perform vertebral fracture assessment in association with DEXA 6) men or women on chronic oral glucocorticoids for > 3 months [1] a) within 6 months of starting glucocorticoid b) all patients > 40 years c) patients < 40 years with osteoporosis risk factors or fragility fracture [1] 7) primary hyperparathyroidism 8) patients considering therapy for osteoporosis for which bone mineral density measurements would affect the decision 9) men on androgen-deprivation therapy 10) malabsorption 11) monitoring therapeutic response to bisphosphonates is controversial screening interval 12) optimal screening interval unknown 13) 15 year interval between screenings for women with normal bone mineral density or mild osteopenia (T score > -1.50) 14) 5 year interval screening for women with moderate osteopenia (-1.50 > T score > -2.50) [7] 15) 3 or 4 year interval screening does not improve fracture risk stratification in adults > 75 years of age [8,11] 16) monitoring BMD changes 1-2 years after start of bisphosphonate [1] - monitoring at 4.5-5 year intervals [10] - a decrease in total hip BMD associated with 3% increase in risk for any fracture at 5 years & 5.5% at 10 years, relative to unchanged BMD - an increase in BMD lowers risk of fracture [10] Contraindications: - in otherwise healthy young adults, a low energy fracture is not an indication for bone mineral density assessment [1] - do not repeat in < 2-5 years unless patient is on long-term glucocorticoid therapy [1]* * repeat DEXA is useful in predicting fracture risk [10] - ref [10] recommends repeat DEXA 2-3 years after initiating therapy, then again at 5 years * repeat DEXA measurements do not improve fracture prediction in men [12] * DEXA before & during teriparatide not useful for assessing response to therapy or revision of fracture risk [1] Methods: Bone mineral density measurements: 1) dual energy X-ray absorptiometry (DEXA) 2) single photon absorptiometry (SPA) 3) dual photon absorptiometry (DPA) 4) quantitative computed tomography Interpretation: - Numerical scoring of BMD: - see dual energy X-ray absorptiometry (DEXA) - measurements are imprecise: [5] - bone mineral density measurements within individual patients vary more than measurements between bisphosphonate & placebo recipients [5] Clinical significance: - bone mineral density (BMD) increases with childhood growth & reaches a peak in the 3rd decade of life - subsequently, a slow decline in BMD occurs - a more acute loss in BMD occurs in women at the time of menopause - BMD T-score <= -2.50 defines osteoporosis - BMD T-score -1.0 to -2.4 defines osteopenia - factors increasing bone mineral density a) leptin inhibits bone resorption b) insulin-like growth factor c) growth hormone d) estrogen e) testosterone - etiology of low BMD - CHF (deconditioning) - COPD (deconditioning, glucocorticoids) - kyphosis - lactose intolerance - liver disease - malabsorption - cystic fibrosis - celiac disease - bariatric surgery - inflammatory bowel disease - amenorrhea - early menopause - premature ovarian failure - oophorectomy - hyperthyroidism or over-replacement of thyroid hormone - thyrotoxicosis - hyperparathyroidism (increased PTH) - hyperprolactinemia - androgen insufficiency - low calcium diet - low BMI [4] - immobilization [1] - vitamin D deficiency - hypercalciuria - osteogenesis imperfecta - homocystinuria - hemochromatosis - glycogen storage disease - diabetes mellitus - diabetes mellitus type 1 - diabetes mellitus type 2 - panhypopitutarism - medications - anticonvulsants - glucocorticoids > replacement dose for > 3 months - GnRH agonists, GnRH antagonists - SSRI - thiazolidinediones - aromatase inhibitors - anticoagulants - lithium - older age - female gender - race - 1st degree relative with low bone mineral density [1] * inhaled steroids do not affect BMD in postmenopausal women [3] * polymorphisms in IL-6 gene influence BMD

Related

bone FRAX fracture risk assessment tool hip fracture osteoporosis radiography of spine (vertebral imaging)

Specific

dual energy X-ray absorptiometry (DEXA)

General

radiography (roentgenography)

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2022 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Iris Cantor - UCLA Women's Health Center Osteoporosis Evaluation
  3. Journal Watch 23(6):49, 2003 Elmstahl S et al Is there an association between inhaled corticosteroids and bone density in postmenopausal women? J Allergy Clin Immunol 111:91, 2003 PMID: 12532102
  4. Fernandez-Garcia D et al Thin healthy women have a similar low bone mass to women with anorexia nervosa. Br J Nutr 2009 Mar 23; [e-pub ahead of print] PMID: 19302720 http://dx.doi.org/10.1017/S0007114509274733
  5. Bell KJL Value of routine monitoring of bone mineral density after starting bisphosphonate treatment: secondary analysis of trial data BMJ 2009;338:b2266 http://www.bmj.com/cgi/content/full/338/jun23_2/b2266
  6. U.S. Preventive Services Task Force Screening for Osteoporosis: U.S. Preventive Services Task Force Recommendation Statement Annals of Internal Medicine, January 17, 2011 PMID: 21242341 http://www.annals.org/content/early/2011/01/13/0003-4819-154-5-201103010-00307.full
  7. Gourlay ML et al. Bone-density testing interval and transition to osteoporosis in older women. N Engl J Med 2012 Jan 19; 366:225 PMID: 22256806
  8. Berry SD et al Repeat Bone Mineral Density Screening and Prediction of Hip and Major Osteoporotic Fracture. JAMA. 2013;310(12):1256-1262. PMID: 24065012 http://jama.jamanetwork.com/article.aspx?articleid=1741821
  9. Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
  10. Leslie WD, Majumdar SR, Morin SN et al Change in Bone Mineral Density Is an Indicator of Treatment- Related Antifracture Effect in Routine Clinical Practice: A Registry-Based Cohort Study. Ann Intern Med. 2016 Oct 4;165(7):465-472. PMID: 27428723 http://annals.org/article.aspx?articleid=2534408
  11. Crandall CJ et al. Serial bone density measurement and incident fracture risk discrimination in postmenopausal women. JAMA Intern Med 2020 Jul 27 PMID: 32730575 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2768888
  12. Ensrud KE et al. Repeat bone mineral density screening measurement and fracture prediction in older men: A prospective cohort study. J Clin Endocrinol Metab 2022 Aug 18; 107:e3877. PMID: 35587517 https://academic.oup.com/jcem/article-abstract/107/9/e3877/6589466