Interview with Dr. Lynn Kohlmeier, MD

Dr. Kohlmeier is an endocrinologist in Spokane Valley, Washington. She is an expert in bone, endocrinology, diabetes & metabolism. She received her medical degree from Stanford University School of Medicine and completed her internal medicine residency and her post-doctoral training in Harvard. She has been involved in clinical practice, research and non-pro t community events focusing on improving bone health and preventing fractures for more than 20 years being, moreover executive board member of Washington Osteoporosis Coalition (WOC), Director of WOC-Spokane Division.

Medimaps: As the Director of Spokane Osteoporosis and the Spokane chapter of the Washington Osteoporosis Coalition (WOC), can you tell us about the objectives of WOC and what role TBS could play?

Dr Kohlmeier: WOC objectives are to increase awareness of bone health, osteoporosis and fracture prevention in the state of Washington.

Yes, TBS could help not only with WOC’s goal, but also with our clinical work at Spokane Osteoporosis.

Medimaps: TBS is one of the rst tool to assess bone microarchitecture in routine clinical practice and a predictor of fracture independent of Bone Mineral Density (BMD), clinical risk factors and FRAX®. Although it is endorsed by international scienti c societies, it is still very new to many physicians and medical providers who are testing and treating patients with osteoporosis. You are one of the rst to have experienced TBS in your practice in the USA. How would you introduce TBS?

Dr Kohlmeier: I am a sceptic and usually don’t believe anything until it has been proven beyond doubt with years of post-marketing reassurance. I have been very impressed with the clinical data supporting TBS, Trabecular Bone Score, and remember Prof. Didier Hans presenting the technique at the International Society for Clinical Densitometry several years ago. TBS is adding value to the overall bone assessment and dual X-ray absorptiometry bone mineral density (DXA BMD) measurement without increasing the examination time nor adding radiation dose to the patient.

TBS frequently in uences my clinical decisions and provides not only my patients and me, but also their primary care providers, added reassurance and con dence in our goal to prevent fractures. I always try to show my patients their BMD and TBS results, hoping the impact helps motivate them to improve their bone health as well.

TBS is the «extra» information on bone quality that helps “ ne tune” patient care.

Medimaps: Would you have some examples of patient cases for which TBS plays an important role?

Dr Kohlmeier: Yes. The rst example would be a patient who has not fractured and wants to hold off on treatment. If their BMD is stable with a T-score above -2.5, not in the osteoporotic range, and their TBS bone quality is also stable, above or equal to 1.3, in the moderate range, I believe medical treatment may not yet be needed.

On the other hand, if BMD and or TBS decrease signi cantly with time, the added fracture risk predictability of TBS in combination with BMD, gives me a stronger reason to recommend starting medical treatment.

If a patient asks me if they should continue medical treatment when their BMD has decreased, but their TBS has not, I would say ‘Yes’, provided we have ruled out secondary causes of bone loss and they have a good calcium and vitamin D intake.

Alternatively, if a 55-year old woman with a BMD T-score of -2.5 also has a strong family history of osteoporosis with hip fracture, knowing her TBS bone quality will likely help in her treatment decision. If her TBS is in the moderate or low bone quality range, for example a score of 1.21, I would recommend medical treatment.

Medimaps: So overall, would you say that adding TBS to BMD helps both medical providers and patients decide whether medical treatment is indicated?

Dr Kohlmeier: Yes, TBS can be very useful. A third example where TBS helps is when BMD can be misleading due to arthritis of the spine where a higher BMD T-score will likely result. TBS is not impacted by arthritis as you know.

Consider a typical 72-year-old man with arthritis and a T-score of +1.6 at the spine and -1.8 at the hip, with no other known risk factors and no fracture history. We not only would usually not recommend treatment in this gentleman, but he would likely refuse if offered. Because TBS will give a more accurate assessment of spine bone quality and fracture risk, despite the presence of arthritis, it could in uence treatment. If he had a TBS of 1.190 in the low quality range, I would recommend medical treatment.

Another situation where TBS adds to clinical care is when there is a big discrepancy between spine and hip BMD, such as a spine BMD T-score of -3.5 and hip of -2.4 in a 48-year-old woman with early menopause. Though I would recommend medical treatment, she may likely refuse. If, however her TBS measurement is also in the low bone quality range, for example 1.1, I will likely be able to convince her of the importance of reducing her fracture risk with a treatment.

TBS is also very important in patients referred by their surgeons with «soft intra-operative bones”. Regardless of their BMD, if they have fractured, I treat them as if they have an osteoporosis diagnosis and not only do a metabolic bone workup but also recommend treatment.

Understandably, if these patients are not elderly and have a BMD T-score above -2.5 at the hip or spine, this can still be a dif cult decision and patients again often refuse medical treatment.

If, however their TBS is low, I can explain how this extra information adds to their fracture risk pro le and if not otherwise contraindicated I can often convince them to start medicine for osteoporosis treatment. Studies of TBS measurements in patients with soft intra-operative bone as well as fracture reduction with medical treatment in these patients is of course needed as well.

Patients with multiple fractures yet normal BMD represent the sixth situation where TBS is helpful. Though this scenario would by all accounts justify medical treatment anyway, TBS, if low, can help convince my patients to consider medication and also help guide treatment.

Medimaps: Are there other cases in which TBS can really affect clinical decisions in patients already on medical treatments?

Dr Kohlmeier: Absolutely, in patients who have been on anti-resorptive treatment such as generic Fosamax®, alendronate, or IV Reclast®, zolendronate, for example, 5 or more years, often are told to stop treatment due to the rare risks of atypical femoral fractures or possible association with osteonecrosis of the jaw.

Recently I saw a 62 year-old triathlete with a T-score of -3 at the hip and -3.7 at the spine. She had been on treatment since her hip fracture 10 years ago but had not fractured a bone since then. Her BMD improved signi cantly in the rst 3 to 4 years and was stable since then. Her TBS of 1.30, in the moderate good bone quality range, helped in our decision to stop the potent anti-resorptive she was currently taking which was Prolia®, denosumab and switch to generic Evista®, raloxifene instead to maintain her improved bone status.

TBS also helps in the decision to continue treatment long- term when poor bone quality persists when BMD remains low as well. Given risks of long-term treatment are extremely rare and hip fracture and its consequences on mortality and lifestyle can be devastating, TBS can give me more leverage and credibility to explain to my patients why medical treatment is sometimes important to continue.