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EVALUAREA EVALUAREA DENSITOMETRICA DXA in DENSITOMETRICA DXA in
OSTEOPOROZAOSTEOPOROZA
CODRINA ANCUTAMD, PhD,sef lucrari
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DENSITATEA MINERALA OSOASADENSITATEA MINERALA OSOASA
Determinant major al rezistentei osoase
Factor de predictie risc fractura
Modificarea DMO – reflecta raspuns la
tratament– factor de predictie risc
fractura2
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METODE DENSITOMETRICEMETODE DENSITOMETRICETehnici centrale • cDXA (coloana, sold) & HAS (hip
structural analysis) • qCT (schelet apendicular,
coloana)
Tehnici periferice• pDXA (antebrat, calcaneu)• qCT/ hrqCT (radius, tibie)• QUS (ultrasonigrafie cantitativa)• Radiogrametrie digitala X• Absorbtiometrie radiografica
(direct, digitalizare radiografica)
QUS (transmisie transversala calcaneu si falange; transmisie axiala)
Criterii evaluare metoda
densitometrica• Criterii de baza pt
performanta: acuratete, precizie, reliability
• Procedura definita pt controlul calitatii
• Metode de cross calibrare existente pt diferite centre
• Baza de referinta (sex, virsta)
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EVALUAREA DXA
Avantaje• expunere ↓ la radiatii• precizie f. buna• cost ↓• usurinta folosire• durata redusa tehnica
Limite• bidimensionala (DMO
oase late > DMO oase mici)
• NU evaluaeaza separat os trabecular si cortical
• NU geometria 3D, arhitectura
• artefacte*4
• atenuarea raze X (2 energii) la trecerea prin org• evaluare cantitativa areala DMO pe regiuni de interes
*- vezi la slide limite DXA
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APLICATIILE CLINICE DXAAPLICATIILE CLINICE DXA
• diagnosticul OP (criteriile OMS)• riscul de fractura• stabilirea indicatiei si monitorizarea
tratamentului anti-OP• monitorizarea DMO la normali
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DS ale DMO fata de adultul tanar(DMOpacient – DMOtanarreferinta)/DS tanar referinta
Pentru dignostic OPValori de referinta: -2.5 à 30% cu OP = riscul de fract
SCORUL T versus SCORUL ZSCORUL T versus SCORUL ZScor TScor T Scor ZScor Z
• DS fata de aceeasi varsta si sex
• (DMOpacient – DMO aceeasi varsta)/ DS aceeasi varsta
• Valoare referinta -2DMO mai mica decat cea asteptata pt pacient
• Nu pt diagnostic
6DMO = densitatea areala (g/cm2)PDF created with pdfFactory Pro trial version www.pdffactory.com
CLASIFICAREA OMS CLASIFICAREA OMS 19941994
Categorie DMO si scor TNormal scor T > -1DSOsteopenie -2.5DS < scor T < -1DSOsteoporoza scor T < -2.5 DSOP severa scor T < -2.5 DS + > 1fractura fragilitate
fractura fragilitate à OP indiferent de scorul TCategorii diagnostic difera de categorii tratament
Osteopenia – selecteza pac cu OP in urmatorii 10 ani
DXA OP femei postmeno la coloana, sold, antebrat
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CRITERII DIAGNOSTIC MODERNECRITERII DIAGNOSTIC MODERNEAceleasi valori prag si categorii OMS 1994Aplicabilitate pentru DXA sold la femei si barbati• situs scheletal de referinta (sold)
– Valoare predictiva maxima pt fractura sold (lombar, trohanter, sold total)
• interval de referinta pt femei si barbati (tanar normal) – baza NHANES III pt col femural la femei 20-29 ani
• Acelasi scor T pt locatii si tehnici diferite à informatii diferite pt riscul fractura
• Corelatii slabe inter-situsuri à nu se pot utiliza pt predictie 8
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TIPURI DXATIPURI DXA
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SURSE DE EROARE SURSE DE EROARE DXADXA• Osteomalacie• Artroza (coloana, sold)• Deformari vertebrale dat artroza, Scheuerman• Fractura anterioara (col, sold, pumn)• Scolioza severa• Artroplastie• Obezitate extrema, ascita• Calcificari tisulare (calcificare aorta)• Scintigrafie (tc99) recenta/ imagistica substanta contrast• Baza de referinta inadecvata• Standard operare (calibrare, regiunea selectata, mod achizitie,
pozitionare) 10
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INDICATII TESTARE BMD DXAINDICATII TESTARE BMD DXACategorie Categorie NOFNOF AACEAACE ACRACR ISCDISCD
F > 65 ani + + + +60-64 ani & fact risc
+ + + +
< 60 ani & fact risc
+ + + +
in prezenta fact risc
+ +
B > 70 ani +monitorizare + + +
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Factorii de risc difera fct de organizatie; NOF, National OsteoporosisFoundation; AACE, American Association of Clinical Endocrinologists;ACR, American College of Rheumatology; ISCD, International Society of Clinical Densitometry
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FACTORI RISC OPFactori majori Factori minoriVarsta > 65 ani PR
Fractura vertebrala Hipertiroidism in antecedente
Fractura de fragilitate >40 ani Trat anticonvulsivant cr
AHC fractura (mama sold) Dieta saraca Ca
CS p.o.> 3 luni Fumat
Sdr malabsorbtie Alcool excesiv
Hiperparatiroidism primar Cafea abuz
Tendinta la cadere G>57 Kg
Osteopoenie radiologica Scadere ponderala >10% peste 25 ani
Hipogonadism Anticoagulante cronice
Menopauza precoce (<45 ani)
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OP PREMENOPAUZAOP PREMENOPAUZA
• Nu se utilizeaza in clasificarea OMS a OP• Scor Z
– Nu se utilizeaza pt diagnostic ci ofera informatii despre DMO la femeia in premenopauza si la barbat <50 ani
– Z< -2 à valoare a DMO sub nivelul acceptat pt varsta
– Z> -2 à valoare a DMO in intervalul acceptat pt varsta
– Se utilizeaza pt copil
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RECOMANDARI DXA BARBATRECOMANDARI DXA BARBAT
utilizarea acelorasi valori absolute ale DMO– Diferente intre sexe pt
gradient risc fract– Ajustare virsta pt relatia
DMO-fract – Populatia de referinta– DMO/ scor T cu ajustare
varsta: Riscul fract sold si coloana similar pt F si B pt orice DMO
• screening B > 70 ani• hipogonadism• fractura de fragilitate• medicatie (CS)• boli secundare cu impact pe DMOISCD Consensus Conference 2001
• >50 ani à scor T <-2.5 =OP• <50 ani: se foloseste scorul Z
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ISCD: SITUSURI DE EVALUAT
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ContraindicOA, fract interventie scolioza
ContraindicOA
artroplastie totala HPTH
ContraindicI si II
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ISCD: DXAISCD: DXA
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APLICATIILE CLINICE DXAAPLICATIILE CLINICE DXA
• diagnosticul OP (criteriile OMS)• riscul de fractura• stabilirea indicatiei si monitorizarea
tratamentului anti-OP• monitorizarea DMO la normali
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DXA SI RISCUL FRACTURADXA SI RISCUL FRACTURA
• DXA T4-L4 – img laterala pt deformari vertebre• VFA = vertebral fracture assessment
– ↑ evaluare risc fract (atentie la BMD normal cu fract vert!) – 90% fract grad 2 & 3 Genant
– Radiatie & cost < Rg
• DXA sold à risc fract sold > alte DXA– Risc fract sold= 2.6x pt scadere 1DS– Risc alta fract = 1.5x pt scadere 1DS
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APLICATIILE CLINICE DXAAPLICATIILE CLINICE DXA
• diagnosticul OP (criteriile OMS)• riscul de fractura• stabilirea indicatiei si monitorizarea
raspunsului terapeutic• monitorizarea DMO la normali
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MODALITATI MONITORIZAREMODALITATI MONITORIZARE• Markeri surogat = metode imagistice/biologice/biochimice a
caror modificare sub tratament denota modificari clinice semnificative
• 2 markeri surogat pt raspunsul terapeutic in OP
•Monitorizare densitometrica DMO• ce tip de evaluare DXA (centrala/ periferica)?• ce situs anatomic (col, femur proximal, antebrat)?• la ce interval de timp evaluam?
•Monitorizarea markeri turnover osos 20
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MONITORIZAREA DXAMONITORIZAREA DXA• Care e precizia determinarilor repetate DXA?
• Care e decizia terapeutica functie de modificarea DMO?
• Cat de bine prezice riscul de fractura evaluarea repetata a DMO?
• Care sunt alternativele la evaluarea DMO in dinamica?
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MONITORIZAREA DXAMONITORIZAREA DXAPrecizie
• reproductibilitatea rezultate pt evaluari seriate
• DXA = precizie excelenta • eroarea de precizie =1-2%• variaza cu situsul scheletal
• Modificarea min semnificativa (LSC) = 2.77 x coeficient variatie
• LSC = 5.6% à modificare DMO<5.6% se poate datora erorii de precizie
Raspuns situsului anatomic la trat
Coloana > sold > periferie (antebrat)
• Modificarea DMO fata de baseline este clinic semnificativa sau se datoreaza erorii de masurare?
• Consens: modificarea DMO in dinamica > LSC
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MONITORIZARE DXAMONITORIZARE DXA
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MONITORIZARE DXAMONITORIZARE DXADXA in dinamica - 3 scenarii• ↑ DMO > LSC à acelasi tratament
• ↑ minima DMO à ↓ semnificativ risc fract• Modificarea DMO= factor predictiv risc fract
• DMO stabila à acelasi tratament• ↓ DMO < LSC à reevaluare
• cauze OP secundara• aderenta la trat• persistenta (durata trat)• complianta (administrare –modalitate, doza)
à modificare tratament
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MONITORIZARE DXAMONITORIZARE DXAIntervale de monitorizare• NU se indica monitorizarea frecventa!
• 6-12 luni pt pierdere rapida DMO– GIO, precoce in postmeno, intrerupere HRT
• 18-24 luni – coloana• >24 luni – sold
• DMO initial = fact predictiv risc fractura• Modificarea DMO = fact predictiv risc fractura
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MONITORIZARE DXAMONITORIZARE DXA• Acelasi aparat DXA, acelasi soft
– acelasi tehnician– LSC pt fiecare centru
• Pozitionare corecta
• Precizia situsului anatomic (periferie > coloana > sold)
• Modificarea asteptata DMO la medicatia folosita 26
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MONITORIZAREA MARKERI MONITORIZAREA MARKERI BIOCHIMICI TURNOVER OSOSBIOCHIMICI TURNOVER OSOS
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UTILITATEA BIOMARKERI TURNOVER OSOSUTILITATEA BIOMARKERI TURNOVER OSOS• Turnover-ul osos
• ↑ la menopauza si in OP (25%)
• Niveluri crescute markeri ososi• se asociaza cu risc inalt pierdere osoasa si fractura
• Terapia anti-OP• Modifica markeri turnover osos
• Monitorizarea terapiei• Scopul = ↓ markeri turnover < LSC si in intervalul de pre-
menopauza
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MONMONIITORIZARE TORIZARE –– MARKERII TURNOVER OSOSMARKERII TURNOVER OSOS• Relatie turnover osos &
risc fractura• Anti-OP ↓ turnover osos
sapt-luni à ↓rata fractura in 6-12 luni
• Markeri rezorbtie• urinar (CTX/cr, NTX/cr)• seric (CTX, NTX)
• Markeri formare osoasa• seric: osteocalcina, bALP,
P1NP
• Modificare precoce à status premonopauza à reflecta raspuns terapeutic
• Antirezorbtive - ↓ markeri nivel premeno•3-6 luni - rezorbtie•6-9 luni - formare
• Osteoformatoare - ↑P1NP in 1-3 luni de 2-3x
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TERAPIA OP TERAPIA OP –– ACTIUNE PE REMODELARE ACTIUNE PE REMODELARE OSOASAOSOASA
Medicatie anti-catabolica
• HRT/E• SERM: raloxifen• BF
– Etidronat– Alendronat– Risendronat– Ibandronat– Acid zolendronic
• calcitonina
Medicatie anabolica
• Teriparatide• PTH 1-84
Ranelat strontiu
Scade etapa activareReechilibrarea remodelarii
Creste frecv etapa activareBalanta + remodelare
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MARKERI TURNOVER OSOS
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EVALUARE IN DINAMICAEVALUARE IN DINAMICA• Identificarea precoce a raspuns deficitar
• complianta & persistenta limitate• OP secundara• tratament ineficient
• Interventie pt ameliorarea raspunsului terapeutic• adminstrare si dozare corecta• investigarea cauze OP secundara• modificare doze sau modificare tratament
• Cresterea compliantei• fara beneficii imediate asupra pacientului simptomatic 34
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MONMONIITORIZARE TORIZARE –– MARKERII TURNOVER OSOSMARKERII TURNOVER OSOS
Marker surogat pt• monitorizarea precoce raspuns terapeutic
• predictia riscului de fractura• Fact independent pt risc fractura sold
• NU valoare pt diagnostic 35
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ghid terapeutic ESCCEO 2008
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DEZIDERATE TERAPEUTICE OP
• cresterea rezistentei osoase & scaderea riscului de fractura
• cresterea si/sau mentinerea DMO in interval de normalitate
• Imbunatatirea microarhitecturii osoase
Fractura • ameliorarea durerii osoase• stabilizarea /refacerea
anatomica• tratamentul comorbiditatilor• refacerea functionalitatii • suport psihologic
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MEDICATIA ANTI-OPANTI-REZORBTIVE
bisfosfonati§ Alendronat § Risedronat § Ibandronat § Zolendronat
SERMs§ raloxifen (RLX)§ lasofoxifen, arzoxifen
estrogeni (E)calcitonina (CT)
OSTEOANABOLICE
rhPTH (1-34) = teriparatidePTH (1-84)
ranelat de strontiu (SR)
Denosumab
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MEDICATIA ANTI-OP FDAANTI-REZORBTIVE
Bisfosfonati§ Alendronat 10mg/zi, 70mg/sapt§ + vitam D 2800/5600UI
§ Risedronat 5 mg/zi, 35 mg/sapt§ 70mgx2/luna, 2 zile consecutiv§ 150 mg/luna
§ Ibandronat 150 mg/luna, 3mg iv /3 luni
§ Zolendronat 5 mg iv/an SERMs§ raloxifen (RLX)
estrogeni (E)calcitonina (CT)
OSTEOANABOLICE
rhPTH (1-34) = teriparatidePTH (1-84)
ranelat de strontiu (SR) 2g/zi(EMEA, Nu FDA)
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INDICATII TERAPEUTICE FDA § OP FEMEI POSTMENOPAUZA
– preventie: ALN, RIS, IBN, RLX– tratament: ALN, RIS, IBN, RLX, CT, PTH
§ OP CORTICOID-INDUSA– preventie: RIS– tratament: ALN, RIS
§ OP BARBAT- ALN, PTH/ teriparatide
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RECOMANDARI TERAPEUTICERECOMANDARI TERAPEUTICEProfil pacientProfil pacient NOFNOF AACEAACEFara factori de risc < -2.0 < -2.5Cu factori de risc* < -1.5 < -1.5Fractura de fragilitate
Indiferent scor T
Indiferent scor T
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varsta = cel mai important factor predictiv• fract anterioara• istoric familial fract şold• fumat• G<127 lbs (57.7kg)
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CRITERII DE SELECTIE A TERAPIEI
Medicina bazata pe dovezi
• risc fractura• eficacitate DMO• efecte adverse• toleranta
• Comorbiditati• Comedicatie• Cost/beneficiu• Preferinta pacient• Aderenta
– primara
• Persistenta• Complianta
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