Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole and joining me today t  highlight bone density in clinical practice is Dr. Basma Abdulhadi. She's an Assistant Professor in the Division of Endocrinology, Diabetes, and Metabolism at UAB Medicine.

Dr. Abdulhadi, thank you so much for joining us today. I'd like you to speak about why it's important to monitor bone density in clinical practice as we begin. How is this used not only to diagnose osteopenia, osteoporosis, and other bone disorders, but really to assess that fracture risk and guide those treatment decisions.

Basma Abdulhadi, MD: thank you for having me, Melanie. For us to talk about bone DEXA scans, we need to talk about osteoporosis. So osteoporosis is a condition that causes brittle bones. So the bones become brittle enough that even, a fall from standing high or even mild stressors like bending over or coughing can cause a bone fracture or a break.

Those fractures are called insufficiency fractures or fragility fractures, and they commonly affect the hip, the spine, and the wrist. There's an estimated 2 million osteoporosis related fractures that occur every year in the United States, and more than 70 percent of those affect women.

Osteoporosis is a silent disease, so patients don't really know that they're losing bone density or that their bones are becoming brittle. So that's why we usually screen for it. And the way we screen for osteoporosis or osteopenia is using a DEXA scan. So the DEXA scan will help us determine whether a patient has normal bone density, osteopenia, or osteoporosis.

Host: Let's speak a little bit more about DEXA and expand on that. Tell us a little bit about how it works and how the results are interpreted. Let's talk about how that all helps to guide those decisions.

Basma Abdulhadi, MD: So a DEXA scan really is a machine that measures bone density. And usually we look at three sites. So we usually look at the lumbar spine and we look at the total hip and the femoral neck areas. Those are the areas that are most commonly going to fracture if someone was to have an osteoporotic fracture.

The DEXA scan machine will help me say that this patient has either normal bone density, osteopenic bones, or osteoporotic bones. It also gives me something called a FRAX score or a fracture risk assessment score. Now this score we usually use in patients who have osteopenia. And it allows us to incorporate some of the risk factors into assessing their bone density or their risk for fracturing.

So let's say someone is a heavy smoker or is using steroids or has rheumatoid arthritis, so things that would increase their risk for osteoporosis and bone loss; this gives me a fracture risk assessment and it tells me what the risk of fracturing over the next 10 years is. So it kind of helps us in our decision making process as to whether we need to treat this patient or monitor them.

Host: Well, then let's talk about some of the treatment modalities based on those results. And you mentioned osteopenia and then osteoporosis and fracture risk. What are some of the latest and most exciting treatments to help stave off those fractures and or osteoporosis?

Basma Abdulhadi, MD: So I always tell my patients that the first thing that we really have to address is really exercise and stability. So the number one reason people fracture when they have osteoporosis is because of a small fall. So we really need to make sure that the patient's evaluated by a physical therapist, that we work on their gait, reduce their fall risk as much as we can.

So we usually, in our clinic, we'll start by having the patient be evaluated by a physical therapist. The next step would be to evaluate whether the patient has secondary causes for osteoporosis. So some patients might have hyperthyroidism, hyperparathyroidism, they might have other causes that may be contributing to their bone loss.

So we would need to do investigation to make sure that there's not a secondary cause for their bone loss that we can actually treat. If we've established that this is just osteoporosis without any secondary causes, then there's different modalities to treat that. We have a wide variety of medications that we can use.

Some are pills, some are injections, and some are infusions. I think what's been really exciting recently is our anabolic medications. And those are medications that can help build bone. So we have two different categories of medications that we use to treat osteoporosis. So some of them are called antiresorptive medications. So those are the medications that prevent bone loss. And then we also have anabolic agents and those are medications that help build up bones.

So we have a wide variety of different medications that we can use. The way the patient presents really dictates a lot of times what we end up using. So if someone comes to us with vertebral fractures or a history of a hip fracture and their T scores are pretty low, we would tend to be more aggressive and we would probably start with something like an anabolic agent first. We have to factor in the whole patient picture before we can actually decide on therapy.

Host: Certainly, and how does your treatment modality change based on the lifestyle of the patient? If they are a current smoker, if they have previous fractures or at an increased risk because of bone mineral density, any of those things. How does that guide your treatment choices?

And tell us about working with other providers in a multidisciplinary approach to help guide those treatment decisions, whether it's a nutritionist or somebody to help them with weight training and body weight exercises. Tell us a little bit about that.

Basma Abdulhadi, MD: So in our osteoporosis clinic, we definitely have a multidisciplinary team and we have a multidisciplinary approach to treating osteoporosis. So as I said, the first encounter the patient would have is typically with our physical therapist who's going to do a physical therapy screen.

They're going to assess the patient for fall prevention. They're going to do a gait analysis. They sometimes can address things like chronic back pain and things like that. They tend to give them exercises that can help them become more stable on their feet. And then we also, in our osteoporosis clinic at UAB, we have physicians from different specialties. So I'm an endocrinologist myself. There's a few other endocrinologists in the team. We also have a rheumatologist, a geriatrician that also works with us, and we all practice together in the same place. The nice thing about our clinic as well is we also have a pharmacist in house that also is available to talk to the patients.

So a lot of these newer medications, injectable medications, the pharmacist would come and sit with the patient and talk about how they can store the medication, how they can inject it, what side effects to expect and whatnot. We also work closely with our kidney doctors cause there's a lot of overlap between osteoporosis and chronic kidney disease. So we also collaborate with a nephrologist here at UAB.

Host: It's such a comprehensive patient centered approach, Doctor, so I'd like you to summarize for other providers what you would like them to know about bone density and DEXA and why it's so important to monitor their patients for risk of fracture, osteoporosis, osteopenia, to monitor their patients in their clinical practice.

Basma Abdulhadi, MD: So it's very important to screen for osteoporosis because it's a silent disease. So the only time a patient will have complaints is usually when they've already fractured something. So patients can come and say, you know, I have back pain because they have compression fractures or I have I have lost a few inches over time or I have a stooped posture because they have osteoporosis.

So screening for osteoporosis will help us address this issue before we reach that fracture risk. There are treatments available that can address osteoporosis and hopefully prevent fractures from occurring. So it's very important to screen patients. Postmenopausal women age 65 and older usually will need a screening DEXA scan to see what their bones are doing.

A patient with a history of a fracture will usually also need a DEXA scan to screen for osteoporosis. Patients who are on long term steroids, for example, also need to be screened. Patients with certain medical conditions like rheumatoid arthritis or hyperparathyroidism, also need a DEXA scan to screen for osteoporosis or osteopenia because they have a high risk of developing those conditions.

So it's very important to screen so that we can catch this early and treat it and maintain bone density.

Host: Thank you so much, Doctor, for joining us today. And for more information, you can visit our website at uabmedicine.org/physician. That concludes this episode of UAB Medcast. I'm Melanie Cole. Thanks so much for joining us today.