Q:

9/17/2012
At what age do you recommend DEXA Scan for patients on daily ICS?

A:

Thank you for your inquiry.

Unfortunately there are no formal guidelines which state when to use DEXA for patients on chronic inhaled steroid therapy or patients who have had pulse therapy. However, my best interpretation of the general osteoporosis management guidelines is that such patients should be considered at risk and therefore DEXA may be indicated. There are a number of factors which would impact on when to obtain a DEXA, and therefore, no dogmatic age can be confidently stated as to when this test should be performed. It is really based upon the clinical judgment of the physician caring for the patient. The factors that may impact on whether or not to evaluate a patient for osteoporosis/osteopenia are the dose administered, the duration of therapy, whether or not the patient has had intermittent oral pulses of corticosteroid therapy, and if so, the dose of these courses and their frequency.

Finally, there are a number of other risk factors which play into this decision. They are listed for you below:

• Age greater than 65
• Vertebral or compression fracture
• Family history
• Glucocorticoid therapy (7.5 mg prednisone or equivalent for > 3 months or 2.5 mg prednisone daily)
• Osteopenia on x-ray
• Hypogonadism
• Early menopause (before age 45)
• Rheumatoid arthritis
• History of hyperthyroidism
• Anticonvulsant therapy
• Low dietary calcium
• Smoker
• Alcohol intake
• Caffeine intake
• Weight less than 57 kilograms
• Weight loss greater than 10% of weight at age 25
• Chronic heparin therapy

It should be noted that, as mentioned, although guidelines do not state any particular recommendation regarding inhaled or intranasal corticosteroids, inhaled corticosteroids have been shown to reduce bone density. Also, in terms of oral corticosteroids, there are no formal recommendations at this time that state the risks of intermittent courses of high or moderate doses of prednisone (e.g., two to three courses a year for asthma flares).

Thus, as noted, I cannot give you a dogmatic or definitive answer to your question, but only cite for you the above information which is based upon a reading of the references noted below. A review of these references will help you understand the nuances underlying this response to your inquiry.

Having stated the above, in general I consider menopause as thee first age in women and 60 to 65 as the first age in men.

References:
1. Brown JP. 2002 Clinical Practice Guidelines for Diagnosis and Management of Osteoporosis in Canada.
2. NIH web site.
3. CDC website.
4. Updated Guidelines of the North American Menopause Society, June 5, 2006.
5. Screening for Osteoporosis in Men: A Clinical Practice Guideline from ACP.
6. Israel E, et al. Effects of inhaled glucocorticoids on bone density in pre-menopausal women. New England Journal of Medicine 2001; 345:941.
7. Journal of Clinical Densitometry, Volume 7, Pages 1 through 5, 2004 (official position of the International Society for Clinical Densitometry).
8. Eberling P. Osteoporosis in Men. New England Journal of Medicine 2008; 358:1474-1482.

Thank you again for your inquiry, and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology