What Is the Role of Serial Bone Mineral Density Measurements in Patient Management?

doi:10.1385/JCD:5:3S:S29

Journal of Clinical Densitometry

Volume 5, Issue 3, Supplement, Autumn 2002, Pages s29-s38

https://doi.org/10.1385/JCD:5:3S:S29 Get rights and content

Abstract

The ability of dual X-ray absorptiometry (DXA) to monitor bone mineral density (BMD) has been well documented in epidemiologic and pharmaceutical trials. However, its application to monitoring of patients in clinical practice has been subject to recent controversies. Despite these controversies, most clinical centers rely on DXA for monitoring of patients, and therefore guidance is needed. In this article, we report the positions developed by an expert panel of the International Society for Clinical Densitometry on the use of densitometry for the serial measurement of bone mass for monitoring change in BMD. The panel found DXA to be a precise method of measuring change in BMD if used with an appropriate level of least significant change (LSC), at anatomic sites with good precision and response to therapy, and at 1- to 2-yr time intervals. Monitoring is acceptable for determining when therapy is indicated, and if an agent is not therapeutically effective (i.e., when bone loss occurs despite treatment). Each densitometry center should perform an in vivo precision study on individuals similar to the patient population at the center and determine LSC at a 95% confidence level. If such a precision study cannot be performed, benchmark precision might be used, although there was no agreement on what values should be used. The PA spine is the preferred anatomic site for monitoring. The total hip can be used when the spine study is technically invalid. We conclude with recommendations for further research.

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Cited by (149)

Cross-Calibration Study of The Stratos And Hologic QDR 4500A Dual-Energy X-Ray Absorptiometers to Assess Bone Mineral Density And Body Composition
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The objective of the study was to assess the agreement between the Stratos (DMS) and QDR 4500A (Hologic) DXAs in determining whole body and regional aBMD, as well as whole body composition.
Fifty-five individuals (46 women: 84%) with a mean age of 41 ± 13.0 years (range: 20 to 64) and a mean BMI of 31.9 ± 10 kg/m² (range: 12.2 to 49.5) were consecutively scanned on the same day using the two devices. Predictive equations for areal bone mineral density (aBMD) and whole body composition (WBC) were derived from linear regression of the data.
The two DXAs were highly correlated (p<0.001 for all parameters) with a correlation coefficient (r) ranging from 0.89 to 0.99 for aBMD (r=0.89 for whole body, r=0.92 for radius, r=0.95 for femoral neck, r=0.96 for total hip, and r=0.99 for L1-L4). For WBC, the r value was 0.98 for lean tissue mass (LTM) and 1.0 for fat mass (FM). Paired t-tests indicated a statistically significant bias between the two DXAs for the majority of measurements, requiring the determination of specific cross-calibration equations. Compared to QDR 4500A, Stratos underestimated whole body aBMD and LTM and overestimated neck and hip aBMD and whole body FM. Conversely, no significant bias was demonstrated for mean aBMD at L1-L4 and radius. For whole body aBMD and FM, the concordance between the two DXAs was influenced by BMI.
Despite a high concordance between the two DXAs, the systematic bias for aBMD and WBC measurements illustrates the need to define cross-calibration equations to compare data across systems.
Positions of The International Society for Clinical Densitometry and Their Etiology: A Scoping Review
2023, Journal of Clinical Densitometry
The International Society for Clinical Densitometry convenes a Position Development Conference (PDC) every 2 to 3 years to make recommendations for guidelines and standards in the field of musculoskeletal measurement and assessment. The recommendations pertain to clinically relevant issues regarding the acquisition, quality control, interpretation, and reporting of measures of various aspects of musculoskeletal health. These PDCs have been meeting since 2002 and have generated 214 Adult, 26 FRAX, 41 pediatric, and 9 general nomenclature consideration positions, for a total of 290 positions. All positions are justified by detailed documents that present the background and rationale for each position. However, the linkage to these publications is not maintained by the ISCD or any other publication such that physicians cannot easily understand the etiology of the positions. Further, the wording of many positions has changed over the years after being reviewed by subsequent PDCs. This scoping review captures the references, changes, and timeline associated with each position through the 2019 PDC. It is meant to serve as a guide to clinicians and researchers for intelligent use and application of the positions.
Comparison of the Lunar Prodigy and Stratos DR Dual-Energy X-Ray Absorptiometers to Assess Regional Bone Mineral Density
2022, Journal of Clinical Densitometry
Citation Excerpt :
Consequently, regression equations for translating scans between the Stratos DR and Prodigy are valid only for the conditions presented in this study. Evaluation of lumbar spine aBMD is essential for diagnosing osteoporosis because this bone site is preferentially affected by demineralisation after menopause(21) and also because the effect of osteoporotic drugs is particularly marked at this bone site (24). Experimental study has demonstrated that projectional DXA measurements in human cadaveric spine phantom are significantly affected by the positioning of the lumbar spine, but more severely by kyphotic than lordotic curvature (13).
Purpose: The first objective of the study was to assess the agreement between the Stratos DR (DMS) and the GE Prodigy (GE) DXAs in determining femoral neck, total hip and lumbar spine aBMD. The second objective was to assess the potential impact of leg positioning (hip flexed at 90° or not) on lumbar spine aBMD. Methods: Forty-six individuals (n=42 women, 91.3%), with a mean age of 59.7 ± 13 years and mean BMI of 23.8 ± 4.7 kg/m², were scanned consecutively on the same day using the two devices. In a subgroup (n=30), two consecutive Stratos DR scans (with hip flexed at 90° or not) at the lumbar spine were conducted. Predictive equations for hip and lumbar spine aBMD were derived from linear regression of the data. Results: Correlation coefficients for aBMD measured with the two DXAs were characterised by an R² of 0.76 for the femoral neck, 0.89 for the total hip, and 0.86 for the lumbar spine. However, the derived equations for aBMD determination showed an intercept significantly different from 0 for hip aBMD, and a slope significantly different from 1 for lumbar spine aBMD. These results highlight a bias between the two measurements, thus requiring the determination of specific cross-calibration equations for hip and lumbar spine, femoral neck excepted. When compared with values on the Prodigy, mean aBMD on the Stratos DR was higher at the femoral neck (+4.8%, p<0.001) and total hip (+9.6%, p<0.001) and lower at L2-L4 (-8.8%, p<0.001). The coefficient of variation (CV%) for the two consecutive measures at lumbar spine (with different positioning) with the Stratos DR was 2.9%. Conclusions: The difference in aBMD measured with the two DXAs illustrates the need to define cross-calibration equations when comparing data across systems in order to avoid erroneous conclusions.
The impact of acute fracture on interpretation of bone turnover marker measurements for patients starting anti-resorptive therapies
2022, Bone
Bone turnover markers (BTM) are used in evaluating patients' response to anti-resorptive agents (ARA). Fracture and its healing process, however, can influence the measurements, which might make their interpretation difficult in patients with a recent fracture. We aimed to evaluate the effect of oral ARA on changes in BTM levels in patients with a recent distal radius fracture (DRF).
In 143 women who had a new DRF and then received oral ARA including selective estrogen receptor modulator (SERM, n = 101), and bisphosphonate (n = 42), we measured serum cross-linked C-telopeptides of type I collagen (CTXI) and osteocalcin, at baseline and six months, as well as lumbar and total hip bone mineral density (BMD) at baseline and one year after fracture. We determined the predictive value of BTM at six months in determining one-year responses in BMD.
Both BTM levels decreased significantly at six months, with the average decrease of 27 ± 63% for CTX-I and 11% ± 37% for osteocalcin. The percent changes of BTM at six months were independent predictors of the BMD change. Cutoff points of 50.0% CTX-I decrease and 23.5% for osteocalcin decrease had the highest sensitivities and specificities for detecting BMD responders for bisphosphonate users, but cutoffs could not be found for SERM users.
Although a fresh fracture can influence BTM, ARA therapy significantly reduced their levels and their percent change at six months could predict BMD improvement at one year. However, adjusted cutoff points can be necessary to increase sensitivity for detecting patients responsive to ARA treatment after a new DRF.
American association of clinical endocrinologists/American college of endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis-2020 update
2020, Endocrine Practice
The development of these guidelines is sponsored by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPGs).
Recommendations are based on diligent reviews of the clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols.
The Executive Summary of this 2020 updated guideline contains 52 recommendations: 21 Grade A (40%), 24 Grade B (46%), 7 Grade C (14%), and no Grade D (0%). These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world care of patients. The evidence base presented in the subsequent Appendix provides relevant supporting information for the Executive Summary recommendations. This update contains 368 citations: 123 (33.5%) evidence level (EL) 1 (highest), 132 (36%) EL 2 (intermediate), 20 (5.5%) EL 3 (weak), and 93 (25%) EL 4 (lowest). New or updated topics in this CPG include: clarification of the diagnosis of osteoporosis, stratification of the patient according to high-risk and very-high -risk features, a new dual-action therapy option, and transitions from therapeutic options.
This guideline is a practical tool for endocrinologists, physicians in general, regulatory bodies, health-related organizations, and interested laypersons regarding the diagnosis, evaluation, and treatment of postmenopausal osteoporosis. (Endocr Pract. 2020;26 (Suppl 1):1-44)
Utility of DXA for monitoring, technical aspects of DXA BMD measurement and precision testing
2017, Bone
Citation Excerpt :
A common problem for DXA reporters and clinicians is when to perform the next DXA scan. A repeat DXA scan in 1–2 years makes sense following most interventions [7,22,24,28–32,90], particularly after commencing osteoporosis therapy. The majority of patients would be expected to meet or exceed the LSC at the lumbar spine within 1–2 years in a quality DXA facility, but not perhaps the hip (Fig. 3).
Monitoring a patient's bone mineral density (BMD) is one of the main reasons for dual-energy X-ray absorptiometry (DXA) referral. It is widely recommended by clinical guidelines, and the accepted standard in practice for managing patients with osteoporosis and other disorders. Clinicians and DXA providers must be familiar with the scientific rationale and procedures involved in measurement science to obtain accurate and reproducible results. Their importance is critical to maximise the value of scan acquisition and interpretation. Scanning individual patients, with different needs and disorders, requires excellence in training, experience, and is more complex than just simply ‘measuring BMD’. Over the past 3 decades many studies have validated the importance of monitoring BMD for fracture risk assessment, and for patients on osteoporosis treatment. New DXA features enhance the value of DXA monitoring today. Quality BMD measurement remains an essential component of patient care in osteoporosis and other disorders, playing a critical role in informed decision making for clinicians assessing and managing their patients. In this article we describe some of the technical aspects of measurement and discuss the utility of DXA for monitoring patients in clinical practice.

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Position StatementWhat Is the Role of Serial Bone Mineral Density Measurements in Patient Management?

Abstract

J Clin Densitom

Lancet

Am J Med

J Clin Densitom

J Clin Densitom

J Clin Densitom

J Clin Densitom

Bone

J Clin Densitom

Bone Miner

Obstet Gynecol

J Clin Densitom

Noninvasive assessment of bone mineral and structure: state of the art

J Bone Miner Res

Apparent pre- and postmenopausal bone loss evaluated by DXA at different, skeletal sites in women: the OFELY cohort

J Bone Miner Res

The rate of bone mineral loss in normal men and the effects of calcium and cholecalciferol supplementation

Ann Intern Med

The effects of menopause on longitudinal bone loss from the spine

Calcif Tissue Int

Alendronate for the prevention and treatment of glucocorticoid-induced osteoporosis

N Engl J Med

Longitudinal measurements of bone density and biochemical indices in untreated primary hyperparathyroidism

J Clin Endocrinol Metab

Prevention of osteoporosis after cardiac transplantation

Transplantation

Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older

N Engl J Med

Effects of raloxifene on bone mineral density, serum cholesterol concentrations, and uterine endometrium in postmenopausal women

N Engl J Med

The effect of postmenopausal estrogen therapy on bone density in elderly women

N Engl J Med

The effects of testosterone on osteoporosis in men

Clin Endocrinol

Treatment of postmenopausal osteoporosis with transdermal estrogen

Ann Intern Med

Effect of risedronate on the risk of hip fracture in elderly women. Hip Intervention Program Study Group

N Engl J Med

Treatment of postmenopausal osteoporosis with slow-release sodium fluoride

Ann Intern Med

Intermittent cyclical etidronate treatment of postmenopausal osteoporosis

N Engl J Med

Precise measurement of vertebral mineral content using computed tomography

J Comput Assist Tomogr

Long-term precision of bone loss rate measurements among postmenopausal women

Calcif Tissue Int

Bone mineral density in healthy normal women and reproducibility of measurements in spine and hip using dual-energy X-ray absorptiometry

Br J Radiol

Enhanced precision with dual-energy X-ray absorptiometry

Calcif Tissue Int

Position Statement
What Is the Role of Serial Bone Mineral Density Measurements in Patient Management?