Clinician

Lecture 12
Cases for Discussion

IOF / ISCD Clinician Densitometry Certification Course
Note: Discussion of these cases does not necessarily reflect official positions of
either the ISCD or IOF. These cases are designed for general discussion and do not
imply a single “best” approach.
IOF-ISCD Learning Objectives
• Apply knowledge of DXA interpretation and clinical assessment and treatment

to patient case examples
• Recognize the potential for secondary causes of osteoporosis and
evaluate/treat appropriately
Lecture 12 Cases for Discussion
Case 1
• 84 year old Caucasian woman

• Maternal history of hip fracture
• Current medication: hydrochlorothiazide, metformin, L-thyroxine,
omeprazole, SSRI
• Left wrist fracture at age 65
• Vertebral fracture in 2008; treated with vertebroplasty
• At that time was started on alendronate 70 mg weekly + 1000 mg of
calcium carbonate and 800 IU of vitamin D, both daily
• Follow up DXA in 2010; report notes dramatic spine BMD increase but
a decline at the hip
3
Case 1
Prior L1-4 BMD = 0.881 g/cm2

(Difference of 0.133 g/cm2)
Note: L1-4 BMD LSC at

this facility = 0.040 g/cm2
Case 1
Prior Total Femur BMD

= 0.824 g/cm2
(Difference of -0.046 g/cm2)
Note: Total femur BMD LSC at

Case 1: Follow-up After L1 Exclusion
Prior L2-L4 BMD = 0.986 g/cm2

(Difference of -0.101 g/cm2)
Note: L2-4 BMD LSC at

6
Case 1: Teaching Points
• Always review the DXA images

• Consider excluding vertebral bodies not within 1 SD of adjacent vertebral
body, if anatomically abnormal
• Major BMD change (in either direction) requires evaluation for technical issues
• Knowledge of precision and LSC is needed to monitor treatment
• Decline in BMD on treatment requires evaluation
Case 2
55 yo woman: shoulder pain
Humeral radiograph read as “osteopenia”
• More history
• Menopause ~ 5 years ago
• No symptoms currently
• No history of fragility fracture
• No height loss
• Maternal history of hip fracture
• Non-smoker, one glass of wine daily
• Regular exercise (walks 3-4 times per week)
• Calcium intake ~600 mg/day
• Is there an indication for bone density measurement?
Case 2: Baseline DXA
9
10
Case 2
Diagnosis:
• Postmenopausal osteoporosis?
11
Case 2
Diagnosis:
• Postmenopausal osteoporosis of this severity would be unusual at
this age….
• Search for secondary causes!
12
Case 2
• Additional history:
• Flatulence occurring quite regularly for “ages”
• Intermittent slight diarrhea
• Diffuse bone/muscle pain
• Laboratory investigation?
13
Case 2
Laboratory investigation:
Blood Normal Range Result

Hemoglobin g/dl 12.0-16.0 11.6
Erythrocytes Million/mcL 4.0-5.3 4.68
MCV fl 82-100 75.2
MCHC g/dl 320-360 306
Platelets 1,000/mL 150-450 201
Leukocytes Cells/mcL 4,000-10,000 5,000
14
Case 2: Lab Results
Result Normal
Calcium 9.0 mg/dL 8.2-10.2
Magnesium 1.9 mg/dL 1.6-2.6
Phosphorus 3.5 mg/dL 2.3-4.7
Creatinine 0.8 mg/dL 0.55-1.02
Alk. Phosphatase 186 IU/L 40-150
Intact PTH 92 pg/mL 9-77
25-OH Vitamin D 8.2 ng/mL 30-80
SGPT 20 U/L 0-55
15
Case 2
Conclusion
• Calcium and vitamin D deficiency with secondary
hyperparathyroidism
• Suspicion of osteomalacia
• Iron deficiency anemia possible
16
When to Test for Celiac Disease in Patients

with Osteoporosis
• 24 hour urine calcium < 60 mg/day despite good calcium intake, normal
vitamin D and normal GFR
• Unexplained iron deficiency
• Irritable bowel symptoms
• Other autoimmune disorders or family history of celiac
• Loss of BMD, fractures, or sustained high NTX/CTX despite oral therapies
Van der Windt DA et al JAMA 2010

Stenson WF, et al. Arch Int Med. 2005;165:393-9
Buchman A. Arch Int Med. 2005;165:370-2
17
Testing for Celiac Disease
• Tissue transglutaminase IgA antibody for screening

• Excellent sensitivity (>90%) and specificity (>95%)
• Falsely negative in IgA deficiency (2-3% of celiacs)
• May be falsely negative in mild disease
• Others: anti-endomyseal Ab, anti-gliadin Ab
• Genetic testing can reveal permissive genes
• Duodenal biopsy is the gold standard for diagnosis
• Experienced gastroenterologist
• Biopsy of multiple areas
American Gastroenterological Association. AGA Institute medical position statement on the diagnosis and management of celiac
disease. Gastroenterology. 2006;131:1977–1980
18
Case 2
• Suspicion of celiac disease

• Confirmed by positive transglutaminase antibodies
• Treatment:
• Gluten-free diet
• Calcium and vitamin D supplementation
• Vitamin D repletion for vitamin D deficiency
• When would you repeat bone densitometry?
19
Case 2: Follow-up DXA One Year Later
• L1-L4 BMD increased by 16.6%

• Total Hip increased 1.1%, NS
20
Case 2
Teaching Points
• Always consider causes of secondary osteoporosis
• Routine labs can suggest additional evaluation needed
• Diagnosis of a secondary cause can suggest specific treatment – e.g.,
celiac disease requires a gluten-free diet
• Treatment of underlying celiac disease alone can improve BMD
• In patients with celiac disease and other types of malabsorption,
parenteral therapy (IV bisphosphonate, subQ Dmab or PTH) may be
preferable
• After correction of nutritional (e.g. vitamin D) deficiency
21
Case 3
• 62 y/o female with rheumatoid arthritis

• Chronic prednisone therapy; currently on 5 mg/day
• No history of fragility fracture
• Baseline DXA ;L/S see next slide
• Femoral neck T-score = -2.8
• Treated with zoledronic acid
• Reports 2 inch (5 cm) height loss
• No acute episodes of back pain
• One year follow-up DXA report: Increase in lumbar spine BMD
Is this treatment success?
22
Region BMD (g/cm2) T-score

L1 0.895 -2.0
L2 1.000 -1.7
L3 1.265 +0.5
L4 1.324 +1.0
L1-4 1.128 -0.4
L1-2 0.951 -1.8
23
Case 3: Follow-up DXA
Region BMD (g/cm2) T-score

L1 0.883 -2.1
L2 1.080 -1.0
L3 1.736 +4.5
L4 1.425 +1.9
L1-4 1.425 +1.9
L1-2 0.988 -1.5
Note: L1-L2 BMD did not change: from L1-L4 BMD increased from 1.128 to
0.951 to 0.988 g/cm2 1.425 g/cm2
Note: L1-2 LSC at this facility Note: L1-4 LSC at this facility
= 0.055 g/cm2 = 0.035 g/cm2
24
But, Is the BMD Increase Due to New Vertebral
Fracture?
Baseline Follow-up
25
VFA Demonstrates Vertebral Fractures at L3 & L4

Baseline Follow-up
26
Case 3
Teaching Points
• It is necessary to review the scan; make sure that the comparison is
technically correct
• Obtain vertebral fracture assessment or spine imaging when
knowledge of fracture status would alter therapy
27
Case 4
• 69 y/o Black woman; mother with hip fracture

• No fractures; calcium intake – 1500 mg/day with 400 IU vitamin D
• Baseline DXA T-scores: LS -3.0, FN -3.4
• CBC, chemistry, TSH normal
• 24 hour urine calcium: 70 mg/24 hours (60-250)
• 25(OH)D: 10 ng/mL
What treatment would you recommend?
28
Treating Vitamin D Deficiency
• Add an additional 2,000 IU daily and recheck 25(OH)D at 3 months; or:

• 50,000 units vitamin D once per week for 8 weeks is one commonly
used approach
• Reasonable to begin daily supplementation at the same time
• Repeat 25(OH)D in ~3 months
• ~ 1000 IU for every 6-10 ng/mL needed to raise baseline value to > 30
ng/mL
• In this case, baseline 25(OH)D = 10 ng/mL; needs additional ~2000 units
daily to maintain level of ~30 ng/mL
• Recheck 24 hour urCa to assure adequate absorption after correction
of D deficiency
Holick, et. al., J Clin Endo Metab, 2011; 96: 1911-1930
29
Case 4
Teaching Points
• Vitamin D deficiency is common in patients with osteoporosis and is
particularly common in dark-skinned individuals.
• Correction of significant vitamin D deficiency is needed prior to
starting pharmacotherapy
30
Case 5
• 52 year old postmenopausal woman 73kg, 163cm, with inflammatory

bowel disease
• Prednisone 5 to 20 mg daily for the past 4 years. Currently on 5 mg/day
• DXA T-score LS: -2.1, FN -1.8, TH = -1.8 (reviewed scan and it is
technically correct)
• FRAX 10 year risk: MOF: 9.6%; hip fracture: 1.2%
• Complete Blood Count, routine labs(calcium, electrolytes, liver, kidney),
PTH, 25(OH)D and 24-hour urine calcium - normal
Would you order any other tests?
31
Indications for Spinal Imaging
• Lateral spine imaging with standard radiography or densitometric VFA

is indicated when T-score is < -1.0 and one or more of the following is
present:
• Women age ≥ 70 years or men ≥ age 80 years
• Historical height loss > 4 cm (>1.5 inches)
• Self-reported but undocumented prior vertebral fracture
• Glucocorticoid therapy equivalent to ≥ 5 mg of prednisone or equivalent
per day for ≥ 3 months
www.ISCD.org
32
Case 5
VFA
57 y/o with inflammatory bowel disease

on steroids
• 2 vertebral compression fractures
• Strong indication for
pharmacotherapy
• FRAX now:
• MOF 17%,hip 2.4%
33
Case 5
• 52 year old postmenopausal woman with inflammatory bowel disease

on prednisone 5 to 20 mg daily for the past 4 years. Currently on 5
mg/day
• DXA T-score LS: -2.1, FN -1.8, TH = -1.8
• FRAX now: MOF 17%,hip 2.4%
Does she need pharmacologic therapy?
34
Postmenopausal women and men ≥ 50 yrs

committed or exposed to ≥ 3 months oral
glucocorticoids
Counselling and general measures
Previous fracture or age >=70 No previous fracture

yrs or prednisolone >=7.5mg/d
Assess risk: adjusted FRAX ± BMD
Above intervention Below intervention

threshold threshold
Reassure
Consider treatment
Monitor as indicated
Lekamwasam S et al Osteoporos Int 2012; 23: 2257-76
35
Guidance for Glucocorticoid-induced

Osteoporosis (GIOP)
From UK National Osteoporosis Guideline Group (NOGG)
• Women and men age > 70

with a previous fragility
fracture, or taking high doses
of glucocorticoids (> 7.5
mg/day) should be
considered for bone
protective therapy
• In other individuals fracture
probability should be
estimated using FRAX with
adjustment for glucocorticoid
dose
Compston, J., Cooper, A., Cooper, C. et al. Arch Osteoporos (2017) 12: 43. https://doi.org/10.1007/s11657-017-0324-5
36
GlOP Prevention & Treatment Guidelines
American College of Rheumatology
Adults ≥ Age 40 Without Childbearing Potential Fragility fracture
or Men age ≥50
or postmenopausal women with T-score ≤-2.5
or *FRAX ≥10%
or *FRAX hip fx risk > 1%
or Prednisone dose ≥ 30 mg/day and cumulative dose of 5 grams
*Multiply FRAX score by 1.15 if prednisone dose is > 7.5 mg/day
No = Low Risk Yes = Medium - High Risk
Calcium 1000-1200 mg/day Calcium, Vitamin D, healthy lifestyle,
vitamin D 600-800 IU/day plus
Balanced diet, healthy weight, regular
exercise, limit alcohol, avoid tobacco
Monitor First-line: Oral bisphosphonate
2nd: IV bisphosphonate
3rd: Teriparatide
4th: Denosumab
5th: Raloxifene (postmenopausal)
Arthritis Rheum, 69:1521-1537, 2017; slide courtesy of KE Hansen, MD
37
ACR GIOP Guidelines (cont’d) Adults < 40 Years Old

Fragility fracture
or Z-score < -3 at spine or hip and prednisone dose ≥ 7.5 mg/d
or >10% loss of spine or hip BMD over one year
or Prednisone ≥30 mg/day and cumulative dose of 5 grams
No = Low Risk Yes = Medium - High Risk Yes = Medium - High Risk;
Fertile women (any age) Non-fertile Adults
Calcium 1200 mg/day Calcium, Vitamin D, healthy Calcium, Vitamin D, healthy
vitamin D 600-800 IU/day lifestyle, plus lifestyle, plus
Balanced diet, normal
weight, exercise, limit
alcohol, avoid tobacco
Monitor clinically every 12 1st line: Oral 1st line: Oral bisphosphonate
months, repeat BMD if a bisphosphonate 2nd: IV bisphosphonates
risk factor listed above is 2nd: Teriparatide 3rd: Teriparatide
noted 3rd: IV bisphosphonates 4th: Denosumab
4th: Denosumab (teratogen) 5th: Raloxifene (female)
√ BMD if risk factors Repeat BMD in 2-3 years Repeat BMD in 2-3 years
Arthritis Rheum, 69:1521-1537, 2017; slide courtesy of KE Hansen, MD
38
Case 5
• Teaching Points
• GIOP is associated with high fracture risk
• Consider evaluation for “asymptomatic” vertebral fracture in patients
on glucocorticoids
• Underlying disease may contribute to osteoporosis; look for treatable
secondary causes (eg malabsorption with IBD)
• Use lowest possible dose of glucocorticoids; consider alternative,
steroid-sparing therapies if possible
• All steroid-treated patients require sufficient calcium and vitamin D and
consideration of pharmacologic therapy as appropriate
39
Case 6
• Decreased BMD on therapy

• 77 yr old woman with osteoporosis
• Currently on an oral bisphosphonate
• BMD measured at baseline and 2 years later
• Images reviewed and are technically correct
• Signiﬁcant LS BMD ↓ by 9.5%
• Total hip BMD stable
What do you do now?
40
Case 6
• What do you do now?

• Validate DXA comparison √
• Evaluate adherence
• Is she taking her medication? √
• Is calcium and vitamin D intake adequate? √
• Evaluate for secondary causes
What tests would you order now?
41
Case 6
• Baseline labs: CBC, serum Ca & alkaline phos were normal

• New lab tests:
• CBC : WBC = 3,000; Hgb = 11 mg/dL
• Normal serum Ca, alkaline phos, creatinine, LFTs
• 24-hour urine calcium = 380 mg (60-250)
• 25 OH vitamin D = 28 ng/mL
What do you do now?
42
Testing for MGUS or Multiple Myeloma
Test Sensitivity
Serum protein electrophoresis (SPEP) 82%
Serum immunofixation (IFE) 93%
Serum and urine IFE 97%
Serum Free Light Chains
• If in doubt  bone marrow aspiration and biopsy

• This Patient results:
• Monoclonal Kappa light chains in urine and serum
• Bone marrow aspiration – 12% plasma cells
43
Case 6
Teaching Points
• Significant decrease in BMD on therapy is concerning
• Evaluation should include
• Review of the DXA images to ensure they are technically correct for
comparison purposes
• Evaluation for adherence
• Detailed evaluation and treatment of secondary cause
44
Case 7: 75 year old White Female
• Menopause at ~age 50; osteoporosis diagnosed 10 years ago

• Spine T-score -3.1 and femoral neck T-score -2.0 at that time
• Raloxifene for 3 years then alendronate for two years
• Changed to risedronate “because her dental hygienist raised concerns
about teeth”
• Maternal history of osteoporosis (mother with hip fracture and sister
with low BMD)
45
Case 7
• History of chemotherapy (no radiation) due to lung carcinoma (~6 years ago)
• Dietary calcium intake ~1,000 mg daily
• Takes a 1,000 IU vitamin D3 daily
• Type 2 DM for 8 years; on an oral agent
• No tobacco or alcohol
• Seen 1 year previously as had been on bisphosphonates for ~ nine years and:
• BMD stable (VFA showed two mild/moderate fractures at T11 and L3
(presumed old)
• Serum NTX and BSAP in low premenopausal range
• A bisphosphonate holiday was initiated
• Follow up visit one year later to monitor holiday….
46
Case 7: 1 year Follow-up
• No changes in health
• Dietary calcium unchanged; continues on vitamin D 1,000 IU daily
• No falls in the past year
• No fractures
• DXA obtained to monitor her holiday
47
DXA Report
“Impression:
1. The indication for BMD assessment is follow up of patient with osteoporosis

currently on bisphosphonate holiday.
2. BMD measurement shows osteoporosis.
3. Comparison with the last study shows no significant change.”
48
Review the DXA Images
Baseline One-year Follow up
49
Following Review of DXA, Additional History

Was Obtained
• “Strained” her back approximately seven months previously when lifting her
granddaughter
• Evaluated by primary care physician; no imaging studies obtained
• Pain noted to be worse with movement and relieved by laying down
• Prescribed narcotics
• Back pain gradually resolved over ~4 weeks
50
Baseline Follow-up
51
• Always need to critically assess the DXA image

• The majority of vertebral fractures are not appreciated by the patient or their
physician; need to consider spine imaging
• Bisphosphonate holidays are reasonable after long term bisphosphonate use
Discussion Point:
• Assuming labs negative it is reasonable to stop her bisphosphonate holiday;
what treatment would you use?
52
Case 8: 67 year old White male
• Recently relocated and seeing you for the first time regarding
osteoporosis treatment.
• Long smoking history; continues with ~ 2 packs per day
• Has GERD with chronic PPI use
• Recently fell and sustained a pubic ramus fracture
• Has received zoledronic acid annually for three years; last dose ~12
months ago
• Has “low T” and is receiving topical testosterone therapy
53
Endocrine Society Guidance Regarding

Osteoporosis Treatment in Men
What about testosterone therapy??
• We suggest testosterone therapy in lieu of a “bone drug” for men

at borderline high risk for fracture who have serum testosterone
levels below 200 ng/dL on more than one determination, if
accompanied by signs or symptoms of androgen deficiency, i.e.
• Low libido, unexplained chronic fatigue, hot flushes, etc
• If testosterone treatment does not alleviate symptoms of

androgen deficiency after 3-6 months, it should be discontinued
and other therapy considered
Watts, et. al., J Clin Endocrinol Metab, 2012; 97:1802-1822
54
Case 8
• Laboratory evaluation [chemistries, 25(OH)D and total testosterone] all within

normal limits
• DXA report: “BMD establishes the diagnosis of osteoporosis. No prior study
for comparison.”
55
Review the DXA Images
The spine image documents prior laminectomy and also suggests an L2 fracture.
Consider additional spine imaging
T-scores
L1 = -2.2 T-scores
L2 = -2.4 FN = -2.7
L3 = -1.5 TF = -2.0
L4 = -3.4
L1-4 = -2.4
56
VFA identifies multiple

vertebral fractures
(T7, T8, L2 and L3)
57
• Always need to critically assess the DXA image

• Laminectomy lowers lumbar spine BMD and levels with laminectomy should
be removed from analysis
• Spine imaging is important and may affect your treatment decision
• Very high risk for future fracture given his recent fall with pelvic fracture and
multiple vertebral fractures therefore consider:
• Anabolic therapy or
• Continue zoledronic acid for a total of 6 years
58
Case 9
• 56 year old white man with multiple fractures, muscle weakness and
bone pain over past 5 years
• DXA: LS T-score -1.8, FN T-score -1.7, TH = -2.0
• Laboratory evaluation
• Serum and urine calcium normal
• 25(OH)D normal
• CBC and comprehensive chemistry panel all normal
What important lab test is missing?
59
Case 9
• Phosphate = 1.4 mg/dl (2.5-4.5)
• Persistently low serum phosphate leads to inadequate bone mineralization and

osteomalacia
 phosphate caused by:
• Renal phosphate wasting due to excess FGF-23
• Genetic mutations
• Mesenchymal tumors
• Malabsorption
• Malnutrition
60
Tumor-Induced Osteomalacia
• Acquired paraneoplastic syndrome caused by small, slow-growing

mesenchymal tumors secreting FGF-23
• Symptoms: long-standing, progressive muscle and bone pain, weakness,
fatigue and multiple fractures
• Diagnosis usually missed for years
• Tumors often difficult to find
• Lab results: hallmark = low phosphorus
61
Case 9
• Further evaluation: elevated FGF-23

• Negative bone survey by radiography except healed rib and vertebral fractures
• Positive Tc99m sestamibi at mid-tibia and heel
• MRI demonstrated small lesion at tibia
• Patient sent to surgery with complete resolution of his symptoms post-op with
subsequent improved bone density
• Dx: TIO (Tumor Induced Osteomalacia)
62
Case 9
Teaching Points
• Phosphate is missing from routine chemistry profiles and should be
ordered specifically for the evaluation of metabolic bone disease in
patients with unexplained osteoporosis
• Muscle weakness and generalized bone pain are not symptoms
typically associated with osteoporosis. Evaluation of patients with
these symptoms must exclude osteomalacia (TIO and vitamin D
deficiency) and malignancy
63
Case 10: Healthy 68 year old Female With
Knee Osteoarthritis
Total knee arthroplasty performed at age 68
Minimal evaluation
Performed pre-op
i.e., no 25(OH)D
and no BMD
Good immediate
post-op outcome
64
Slipped on Ice 6 Months Later
No additional bone related laboratory testing and no BMD measurement done
65
DXA Done One Year Later

Performed due to initiation of aromatase inhibitor treatment
TBS adjusted FRAX

MOF 31.8%
Hip 11.6%
What evaluation would you do at this time? What treatment?
66
Case 11
• 54 yr old male patient

• Lower back pain since 4 months
Total ALP 2681 U/L (40-129) PTHi 110.5 pg/mL (15.0-65.0)

ASAT (GOT) 36 U/L (10-50) Vit.D3 20.6 ng/mL (30.0-60.0)
ALAT (GPT) 40 U/L (10-50) Osteocalcin 112.5ng/mL (1.0-35.0)
GGT 34 U/L (10-71) PINP >1200.0 ng/mL (16.0-67.0)
LDH 330 U/L (120-240) CTX 2.35ng/mL (0.06-0.35)
Calcitonin <2 pg/mL (0-20)
Rest of chemistry unremarkable Sclerostin 64.8/ pmol/L 10.9-28.7
67
Case 11: DXA
68
Case 11: DXA
69
Case 11: TBS
70
Case 11: Conventional Radiograph
Diffuse bone sclerosis;

entire thoracic and
lumbar spine
Lumbar Spine lat.
Thoracic Spine a.p.
71
Case 11: Additional Tests
Total PSA; 2414.93/+ ng/mL -3.50

Free PSA; 404.84 ng/mL
QfPSA/tPSA 0.17 %
Prostate biopsy: 1-15mm focus of adenocarcinoma in

15/15 tissue samples [Gleason-Score 5+4=9 (grade group 5)].
• MRT spine: Diffuse hypointense signal in T1-weighted sequences in all

vertebrae of the lower thoracic spine, the lumbar spine and the sacral
bone, consistent with (secondary) neoplastic infiltration
Diagnosis:
Osteoblastic bone metastases from prostate cancer
72
• A BMD T/Z-score ≥ +2.5 does not generally indicate normal bone

density but warrants evaluation
• Most commonly reflects degenerative changes or vertebral fracture
• Can also be secondary to an underlying disorder with skeletal effects
Gregson CL et al; Rheumatology 2013; 52: 968-985
73
Case 12
• 65 year old female sustains an T12 fracture while lifting a window blind
• DXA results from age 50
• L1-4: 1.379 g/cm2, T-score + 1.7
• Total femur: 1.239 g/cm2, T-score +1.8
• Current DXA results
She has “normal BMD” but has lost ~21% at the spine and ~27% at hip
Is her bone normal?
(What does her TBS show?)
74
Case 12
75
Case 12 : Teaching Points
• Individuals can have “normal BMD” but have sustained major loss
• It is common for women to experience substantial bone loss due to
estrogen depletion at menopause
• TBS is a bone texture analysis that can provide additional data to DXA
• The following published1 TBS values are consistent with:
• ≥ 1.310 = normal bone microarchitecture
• 1.231 -1.309 = partially degraded microarchitecture
• ≤ 1.230 = degraded microarchitecture
1McCloskey, et. al., J Bone Miner Res, 2015; 31: 940-948
76
IOF-ISCD Learning Objectives
• Apply knowledge of DXA interpretation and clinical assessment and treatment

to patient case examples
• Recognize the potential for secondary causes of osteoporosis and
evaluate/treat appropriately
77

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Lecture 12

Cases for Discussion

IOF-ISCD Learning Objectives

• Apply knowledge of DXA interpretation and clinical assessment and treatment

Lecture 12 Cases for Discussion

• 84 year old Caucasian woman

Lecture 12 Cases for Discussion

Prior L1-4 BMD = 0.881 g/cm2

Note: L1-4 BMD LSC at

Lecture 12 Cases for Discussion

Prior Total Femur BMD

Note: Total femur BMD LSC at

Lecture 12 Cases for Discussion

Case 1: Follow-up After L1 Exclusion

Prior L2-L4 BMD = 0.986 g/cm2

Note: L2-4 BMD LSC at

Lecture 12 Cases for Discussion

• Always review the DXA images

Lecture 12 Cases for Discussion

Lecture 12 Cases for Discussion

Case 2: Baseline DXA

Lecture 12 Cases for Discussion

Lecture 12 Cases for Discussion

Lecture 12 Cases for Discussion

Lecture 12 Cases for Discussion

Lecture 12 Cases for Discussion

Blood Normal Range Result

Lecture 12 Cases for Discussion

Case 2: Lab Results

Lecture 12 Cases for Discussion

Lecture 12 Cases for Discussion

When to Test for Celiac Disease in Patients

Van der Windt DA et al JAMA 2010

Lecture 12 Cases for Discussion

Testing for Celiac Disease

• Tissue transglutaminase IgA antibody for screening

Lecture 12 Cases for Discussion

• Suspicion of celiac disease

Lecture 12 Cases for Discussion

Case 2: Follow-up DXA One Year Later

• L1-L4 BMD increased by 16.6%

Lecture 12 Cases for Discussion

Lecture 12 Cases for Discussion

• 62 y/o female with rheumatoid arthritis

Is this treatment success?

Lecture 12 Cases for Discussion

Case 3: Baseline DXA

Region BMD (g/cm2) T-score

Lecture 12 Cases for Discussion

Case 3: Follow-up DXA

Region BMD (g/cm2) T-score

Lecture 12 Cases for Discussion

Lecture 12 Cases for Discussion

VFA Demonstrates Vertebral Fractures at L3 & L4

Lecture 12 Cases for Discussion

Lecture 12 Cases for Discussion

• 69 y/o Black woman; mother with hip fracture

What treatment would you recommend?

Lecture 12 Cases for Discussion

Treating Vitamin D Deficiency

• Add an additional 2,000 IU daily and recheck 25(OH)D at 3 months; or:

Holick, et. al., J Clin Endo Metab, 2011; 96: 1911-1930

Lecture 12 Cases for Discussion

Lecture 12 Cases for Discussion