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Summary report
Osteoporosis 101 – from
basics to best practice
Learning objectives of Webinar presentation
You will learn:
• To understand that osteoporosis remains severely underdiagnosed and under-treated
• It is important to focus on the fracture risk in osteopenia, as well as the more obvious
fracture risk in osteoporosis
• To understand that bone mineral density (BMD) predicts hip fracture risk with the same
degree of accuracy as hypertension predicts risk for stroke occurrence
Dr Hayley de Wet
• To act on the knowledge that fracture risk increases exponentially with declining BMD
Specialist Physician
Wits University Donald Gordon • To be confident in the diagnosis of premenopausal osteoporosis and osteoporosis in men
Medical Centre • To be aware of the need to maintain healthy bones in all your patients
Johannesburg • To understand the intrinsic factors involved in the causation of falls
• To get to grips with a useful clinical treatment algorithm based on categorisation of patients
at very high risk, high risk and at low risk.
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© 2021 deNovo Medica MAY 2021 I 1
Osteoporosis 101 – from basics to best practice
Key clinical messages
1. The clinical classification of postmenopausal osteoporosis1-3
WHO classification for postmenopausal osteoporosis
The T-score compares an individual’s BMD with the mean value for young “normal” and expresses the
difference as a standard deviation score
T-score (SD)
Normal Equal to –1.0 or higher
Low bone mass (osteopenia) Between –1.0 and –2.5
Osteoporosis Equal to –2.5 or lower
Severe osteoporosis Equal to –2.5 or lower with fracture
2. The changes in bone density with age4-6
Changes in Bone Density with Age
White women
1.2 Peak bone mass
Plateau maintained
Age-related bone loss (–0.5%–1.0% per year)
Spine BMD (g/cm2) by DXA
1.0
Bone loss accelerates with menopause (–1%–5% per year)
Age-related bone loss resumes
0.8
Increase with adolescence
Eventually back to
pre-adolescent levels
0.6
10 20 30 40 50 60 70 80 90 100
Age (years)
2 I MAY 2021
Osteoporosis 101 – from basics to best practice
3. Don’t miss the opportunity to prevent secondary factures
A missed opportunity to
prevent secondary fractures
• Half of patients presenting with hip
fractures have suffered a prior fracture
• Wrist and vertebral fractures are
common first fractures
4. Bone mineral density (BMD) is key to fracture prediction7
BMD predicts hip fracture as well as blood pressure predicts stroke
Cholesterol Blood pressure BMD
12
10
8
Relative risk
6
4
2
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MAY 2021 I 3Osteoporosis 101 – from basics to best practice
5. A declining BMD is a red warning flag
Fracture risk increases exponentially with declining BMD
Gradient of risk • Gradient of risk is characterised by
– Change in risk (e.g. 2-fold) per change in BMD
35 (e.g. 0.1g/cm2)
32 • Gradient is exponential, e.g.
30
– 2-fold – 0.1g/cm2
– 4-fold – 0.2g/cm2
Fold change in fracture risk
25
– 8-fold – 0.3g/cm2
20
16
15
10
8
5 0.1g/cm2
4
0
0.7 0.8 0.9 1.0 1.1
BMD (g/cm2)
6. Principles of osteoporosis diagnosis in premenopausal women
Osteoporosis in premenopausal women
History of low-trauma (fall from standing height or less) fracture in absence of other causes of bone
fragility with or without low bone mass
NB Diagnosis of osteoporosis is NOT made on the basis of DXA-measured BMD values only
4 I MAY 2021Osteoporosis 101 – from basics to best practice
7. Principles of diagnosis of osteoporosis in men
Diagnosis of osteoporosis in men
• Use a uniform Caucasian (non-race adjusted) female reference for men of all ethnic groups
• Age 50 and older
• T-scores are preferred
• The WHO densitometric classification is applicable
• In men younger than age 50, Z-scores, not T-scores are preferred
• A Z-score of –2.0 or lower is defined as “below the expected range for age” and a Z-score above
–2.0 is “within the expected range for age”
8. Who is the patient at risk?
Identify the patient at risk…
• Incident or prior fracture
• Fracture risk assessment with assessment of severity of risk
– BMD scores
– FRAX tool
– Known underlying secondary causes of osteoporosis
• Falls risk assessment
9. Look for factors contributing to falls
Intrinsic factors causing falls
Sensory input CNS
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• Peripheral nerve • motor – strokes
• extrapyramidal
www.denovomedica.com CVS • cerebellar
• postural BP drop • spine: spasticity, sensation
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• dizziness/syncope
Myopathy
MSS
Pain
• joints Peripheral neuropathy
Deformity
• bones
Function
• feet
MAY 2021 I 5Osteoporosis 101 – from basics to best practice
10. What should you do to help prevent falls?
Intervention plan
1. Physiotherapy/Biokinetics for strength and balance training, assessment for assistive devices and
to adddress fear of falling
2. Manage contributory medical problems
3. Rationalise medication
4. Occupational therapy to modify environment to minimise risks and educate
5. Behaviour modification – situational factors usually addressed by physiotherapy and occupational
therapy; remember alcohol
11. Management approach based on risk8,9
Intervention thresholds for osteoporosis therapy based on the
10-year risk of a major osteoporotic fracture in Switzerland
55
50
45 Very high risk
10-yrs probability of MOF (%)
40
35
30
25 High risk
20
15 Moderate and low risk
10
5
0
40 45 50 55 60 65 70 75 80 85 90
Age (yrs)
6 I MAY 2021Osteoporosis 101 – from basics to best practice
Very high risk High risk Low risk
One or more of the following: Post-menopausal age with All of the below are true:
• FX in the past 12 months any of the following: • Age post-menopausal
• Multiple Fx’s • Prior Fx or • No Fx
• Fx on OP Rx • T-score ≤–2.5 • T-score >–1.0
• Very low T-score –2.5 at the hip
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LOW fracture risk Improving but still at risk Fracture risk
www.denovomedica.com
and start to earn today! Consider Continue and ? Adherence
“drug holiday” encourage ? Underlying secondary
Negate long-term cause
side effects ? Treatment failure
Follow up and surveillance Consider treatment change
MAY 2021 I 7Osteoporosis 101 – from basics to best practice
Key learnings
• Standard deviation in DXA T-score is used to classify the severity of postmenopausal osteoporosis
• BMD is key to fracture prediction and a declining BMD is a red warning flag
• The principles of diagnosing osteoporosis in premenopausal women and in men
• Factors that contribute to falls and the interventions to help prevent falls
• Intervention thresholds for osteoporosis therapy and treating to target.
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Southern Africa’s leading References
digital Continuing Click on reference to access the scientific article
Professional Development
1. Hough S, Ascott-Evans B, Brown S, et al. NOFSA guideline for mechanism and implications for the pathogenesis and
website earning FREE
the diagnosis and management of osteoporosis. JEMDSA 2010; treatment of osteoporosis. Endocr Rev 2000; 21(2): 115-137.
CPD points with access to 15(3). 6. Deal C. Potential new drug targets for osteoporosis. Nat Clin
best practice content? 2. World Health Organization. 1994. Technical Report Series 843; Pract Rheumatol 2009; 5(1): 20-27.
Assessment of fracture risk and its application to screening for 7. Cooper C, Aihie A. Osteoporosis: recent advances in
Only a few clicks and postmenopausal osteoporosis. WHO, Geneva. pathogenesis and treatment. QJM 1994; 87: 203-209.
you can register to start 3. Kanis JA, Melton LJ, Christiansen C, et al. The diagnosis of 8. Ferrari S, Lippuner K, Lamy O, et al. 2020 recommendations
earning today osteoporosis. J Bone Miner Res 1994; 9: 1137. for osteoporosis treatment according to fracture risk from the
4. Chavassieux P, Seeman E, Delmas PD. Insights into material and Swiss Association against Osteoporosis (SVGO). Swiss Med
Visit structure basis of bone fragility from diseases associated with Wkly 2020; 150: w20352.
fractures: How determinants of the biomechanical properties 9. Kanis JA, Harvey NC, McCloskey E, et al. Algorithm for the
www.denovomedica.com of bone are compromised by disease. Endocr Rev 2007; 28: management of patients at low, high and very high risk of
151-164. osteoporotic fractures. Osteoporos Int 2020: 31(1): 1-12.
For all Southern African 5. Manolagas SC. Birth and death of bone cells: basic regulatory
healthcare professionals
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This summary report was compiled for
deNovo Medica based on a recent webinar Disclaimer Published by
presented by Dr Hayley de Wet © 2021 deNovo Medica
The views and opinions expressed in the article are those of the presenters and do not necessarily reflect Reg: 2012/216456/07
Specialist Physician, Wits University, Donald those of the publisher or its sponsor. In all clinical instances, medical practitioners are referred to the 70 Arlington Street, Everglen, Cape Town, 7550
Gordon Medical Centre, Johannesburg product insert documentation as approved by relevant control authorities. Tel: (021) 976 0485 I info@denovomedica.com
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