EVALUAREA

DENSITOMETRICA DXA in
OSTEOPOROZA

CODRINA ANCUTA
MD, PhD,
sef lucrari
1

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 DENSITATEA MINERALA OSOASA
Determinant major al
rezistentei osoase

Factor de predictie risc

fractura

Modificarea DMO
– reflecta raspuns la
tratament
– factor de predictie risc
fractura
2

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 METODE DENSITOMETRICE
Tehnici centrale
• cDXA (coloana, sold) & HAS (hip
structural analysis) Criterii evaluare
• qCT (schelet apendicular, metoda
coloana)
densitometrica
• Criterii de baza pt
Tehnici periferice performanta: acuratete,
• pDXA (antebrat, calcaneu) precizie, reliability
• qCT/ hrqCT (radius, tibie) • Procedura definita pt
• QUS (ultrasonigrafie cantitativa) controlul calitatii
• Radiogrametrie digitala X • Metode de cross calibrare
• Absorbtiometrie radiografica existente pt diferite centre
(direct, digitalizare radiografica) • Baza de referinta (sex,
virsta)
QUS (transmisie transversala
calcaneu si falange; transmisie
axiala) 3

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 EVALUAREA DXA
• atenuarea raze X (2 energii) la trecerea prin org
• evaluare cantitativa areala DMO pe regiuni de interes
Avantaje Limite
• expunere ↓ la radiatii • bidimensionala (DMO
• precizie f. buna oase late > DMO oase
mici)
• cost ↓
• NU evaluaeaza separat
• usurinta folosire os trabecular si cortical
• durata redusa tehnica • NU geometria 3D,
arhitectura
• artefacte*
*- vezi la slide limite DXA 4

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 APLICATIILE CLINICE DXA

• diagnosticul OP (criteriile OMS)

• riscul de fractura
• stabilirea indicatiei si monitorizarea
tratamentului anti-OP
• monitorizarea DMO la normali

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 SCORUL T versus SCORUL Z
Scor T Scor Z
DS ale DMO fata de • DS fata de aceeasi
adultul tanar varsta si sex
(DMOpacient – DMOtanar • (DMOpacient – DMO aceeasi
referinta)/DS tanar referinta varsta)/ DS aceeasi varsta

Pentru dignostic OP • Valoare referinta -2

Valori de referinta: -2.5 DMO mai mica decat cea
à 30% cu OP = riscul asteptata pt pacient
de fract • Nu pt diagnostic

DMO = densitatea areala (g/cm2)

6

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 CLASIFICAREA OMS 1994
DXA OP femei postmeno la coloana, sold, antebrat

Categorie DMO si scor T

Normal scor T > -1DS
Osteopenie -2.5DS < scor T < -1DS
Osteoporoza scor T < -2.5 DS
OP severa scor T < -2.5 DS + > 1fractura fragilitate

fractura fragilitate à OP indiferent de scorul T

Categorii diagnostic difera de categorii tratament
Osteopenia – selecteza pac cu OP in urmatorii 10 ani

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 CRITERII DIAGNOSTIC MODERNE
Aceleasi valori prag si categorii OMS 1994
Aplicabilitate 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 DXA

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 SURSE DE EROARE DXA
• 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,
10
pozitionare)
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 INDICATII TESTARE BMD DXA
Categorie NOF AACE ACR ISCD
F > 65 ani + + + +
60-64 ani & + + + +
fact risc
< 60 ani & + + + +
fact risc
in prezenta + +
fact risc
B > 70 ani +
monitorizare + + +

Factorii de risc difera fct de organizatie; NOF, National Osteoporosis

Foundation; AACE, American Association of Clinical Endocrinologists;
ACR, American College of Rheumatology; ISCD, International Society of
Clinical Densitometry 11

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 FACTORI RISC OP
Factori majori Factori minori
Varsta > 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 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 BARBAT

utilizarea acelorasi valori • screening B > 70 ani

absolute ale DMO • hipogonadism
– Diferente intre sexe pt • fractura de fragilitate
gradient risc fract • medicatie (CS)
– Ajustare virsta pt relatia • boli secundare cu impact pe DMO
DMO-fract
ISCD Consensus Conference 2001
– Populatia de referinta
– DMO/ scor T cu ajustare
varsta: Riscul fract sold • >50 ani à scor T <-2.5 =OP
si coloana similar pt F si • <50 ani: se foloseste scorul Z
B pt orice DMO

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 ISCD: SITUSURI DE EVALUAT
Contraindic
OA, fract
interventie
scolioza

Contraindic
OA
artroplastie
totala
HPTH

Contraindic
I si II 15

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 ISCD: DXA

16

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 APLICATIILE 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 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 DXA

• diagnosticul OP (criteriile OMS)

• riscul de fractura
• stabilirea indicatiei si monitorizarea
raspunsului terapeutic
• monitorizarea DMO la normali

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 MODALITATI 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 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 DXA
Precizie Raspuns situsului
anatomic la trat
• reproductibilitatea rezultate pt
evaluari seriate Coloana > sold > periferie
• DXA = precizie excelenta (antebrat)
• eroarea de precizie =1-2% • Modificarea DMO
• variaza cu situsul scheletal fata de baseline este
• Modificarea min semnificativa clinic semnificativa
(LSC) = 2.77 x coeficient variatie sau se datoreaza
• LSC = 5.6% à modificare erorii de masurare?
DMO<5.6% se poate datora erorii • Consens: modificarea
de precizie DMO in dinamica > LSC
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 MONITORIZARE DXA

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 MONITORIZARE DXA
DXA 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 DXA
Intervale 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 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

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 MONITORIZAREA MARKERI
BIOCHIMICI TURNOVER OSOS

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 UTILITATEA 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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MONITORIZARE – MARKERII TURNOVER OSOS
• Relatie turnover osos &
risc fractura • Modificare precoce à status
premonopauza à reflecta
• Anti-OP ↓ turnover osos raspuns terapeutic
sapt-luni à ↓rata fractura in
6-12 luni
• Markeri rezorbtie • Antirezorbtive - ↓ markeri
nivel premeno
• urinar (CTX/cr, NTX/cr)
• seric (CTX, NTX) • 3-6 luni - rezorbtie
• Markeri formare osoasa
• 6-9 luni - formare
• seric: osteocalcina, bALP, • Osteoformatoare - ↑
P1NP in 1-3 luni de 2-3x
P1NP
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 TERAPIA OP – ACTIUNE PE REMODELARE
OSOASA
Medicatie anti- Medicatie anabolica
catabolica
• HRT/E • Teriparatide
• SERM: raloxifen • PTH 1-84
• BF
– Etidronat
– Alendronat
– Risendronat
– Ibandronat Ranelat strontiu
– Acid zolendronic
• calcitonina

Scade etapa activare Creste frecv etapa activare

Reechilibrarea remodelarii Balanta + remodelare

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 MARKERI TURNOVER OSOS

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 EVALUARE 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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MONITORIZARE – MARKERII TURNOVER OSOS

Marker surogat pt
• monitorizarea precoce raspuns terapeutic
• predictia riscului de fractura
• Fact independent pt risc fractura sold

• NU valoare pt diagnostic
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 ghid terapeutic ESCCEO 2008

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 DEZIDERATE TERAPEUTICE OP

• cresterea rezistentei Fractura

osoase & scaderea • ameliorarea durerii osoase
riscului de fractura
• stabilizarea /refacerea
• cresterea si/sau mentinerea anatomica
DMO in interval de
normalitate • tratamentul comorbiditatilor
• Imbunatatirea • refacerea functionalitatii
microarhitecturii osoase • suport psihologic

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 MEDICATIA ANTI-OP
ANTI-REZORBTIVE
OSTEOANABOLICE
bisfosfonati
§ Alendronat rhPTH (1-34) = teriparatide
§ Risedronat PTH (1-84)
§ Ibandronat
§ Zolendronat ranelat de strontiu (SR)
SERMs
§ raloxifen (RLX)
Denosumab
§ lasofoxifen, arzoxifen
estrogeni (E)
calcitonina (CT)

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 MEDICATIA ANTI-OP FDA
ANTI-REZORBTIVE
Bisfosfonati OSTEOANABOLICE
§ Alendronat 10mg/zi, 70mg/sapt
§ + vitam D 2800/5600UI
rhPTH (1-34) = teriparatide
§ Risedronat 5 mg/zi, 35 mg/sapt
§ 70mgx2/luna, 2 zile consecutiv
PTH (1-84)
§ 150 mg/luna
§ Ibandronat 150 mg/luna, 3mg ranelat de strontiu (SR)
iv /3 luni
§ Zolendronat 5 mg iv/an 2g/zi
SERMs (EMEA, Nu FDA)
§ raloxifen (RLX)
estrogeni (E)
calcitonina (CT)

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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 TERAPEUTICE
Profil pacient NOF AACE
Fara factori de risc < -2.0 < -2.5
Cu factori de risc* < -1.5 < -1.5
Fractura de Indiferent Indiferent scor
fragilitate scor T T

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 • Comorbiditati
dovezi • Comedicatie
• risc fractura • Cost/beneficiu
• eficacitate DMO • Preferinta pacient
• efecte adverse • Aderenta
• toleranta – primara
• Persistenta
• Complianta
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