Melanie Cole (Host): Welcome to UAB MedCast. I'm Melanie. Today we're highlighting TRA Bone Score. Joining me is Dr. Basma Abdul Haddi. She's an endocrinologist, the director of bone dense symmetry, and an assistant professor in the division of Endocrinology, diabetes and Metabolism at UAB Medicine. Dr. Abdelhadi, thank you so much for joining us.

I'd like to start with the definition of Ular Bone score and how it extends what we already know from dexa. But before we do that, can you tell us a little bit, give us a little overview of osteoporosis and how that contributes to bone density issues?

Dr Basma Abdulhadi: Thank you so much, Melanie, for having me. Historically, We've defined osteoporosis as a skeletal disease that's characterized by low bone mass and micro architectural deterioration with. Resulting in increase, bone fragility and susceptibility to fracture. We've typically used dexascan to define osteoporosis based on bone mineral density. bone mineral density is a measure of the quantity of mineral in the bone tissue, And we expressed that as a T score comparing the patient's bone mineral density to that of young, healthy adults.

So with bone mineral density, we're talking about quantity of bone. And what we've noticed in our patient's is that a huge proportion of patient's with osteoporosis related fractures actually have BMD scores that are better than, minus 2.5 are osteoporosis. So we're seeing a lot of fractures in patient's with osteo osteopenia or even low bone mineral density.

So This is where Tubular bone score comes into play. So Trab bone score looks at bone quality, so it's an indirect measure of Trab micro architecture or. To simplify it, the structural arrangement of trabu qi in the bone. So this contributes obviously to bone strength, and it can give us information beyond what irregular T-score or bone mineral density can give us.

Melanie Cole (Host): Why do you feel it's so important that bone health clinicians care about TBS in addition to bone mineral density?

Dr Basma Abdulhadi: So TRA bone score is important because it's been found to predict fracture wrist independence of bone mineral density. TBS is a software essentially that we can add to our DEXA scan machines. And it's analyzes the gray level textural patterns in the lumbar spine. So usually we're looking at L one to L four.

when we talk about TBS. it's a number. Again, as I said, it's a unitless value. higher values reflect more homogenous, bone texture, And then lower values reflect more heterogeneous, weaker radicular structures. We will be integrating TBS into our fracs, so the fracture risk assessment score, and it'll adjust the fracs upward or downward depending on its value.

it's really useful to use TBS or to look at TBS adjusted FRAs in patient's with osteopenia or. When their fracture risk is close to intervention, but it's not there yet, So, it can add additional information. It can increase the FRAX risk so that we decide to treat the patient, for example, if they're borderline without the TBS adjusted frax.

so we're excited to be using it at UAB. we are typically gonna include patient's above the age of 40, with a T score of minus 1.1 or lower

Melanie Cole (Host): Then Doctor, it seems particularly informative in conditions where bone mineral density, underestimates risk, but are there populations where it has, in your mind, definitely earned its stripes, like type two diabetes or obesity, these sorts of things.

Dr Basma Abdulhadi: So, it is very useful, in patient's with secondary osteoporosis into your report, Melanie. Patient's with type two diabetes. We know, that their BMDs typically five to 10% higher, than patient's without diabetes, And this higher BMD does not really translate to a lower fracture risk. We actually know that type two diabetics have increased fracture risk, so.

For a hip fracture, it's about 1.5 higher than non-diabetic patient's of a similar age. so in patient's with type two diabetes, TBS could be very useful because it can capture, Deterioration bone quality That is not necessarily reflected in the BMD or T scores.

Melanie Cole (Host): Well there's been enthusiasm 'cause you just mentioned around TBS and postmenopausal women, but what about men, especially older men, is this a tool we're under utilizing in that population?

Dr Basma Abdulhadi: So we can use TBS, in anyone above the age of 40, so men and women. Above the age of 40 BMI is an important aspect. We're only going to be, using TBS for patient's with BMI between 15 and 37 because the values can be reduced if there's excessive, soft tissue in the abdomen.

so our DEXA scan technicians will be screening DEXA scans as they are doing them, anyone above the age of 40 with osteopenia And the BMI between 15 and 37, we will be doing TBS, adjusted facts for those patient's. I will say that TBS has only been validated so far in initial diagnosis, so This is something that we're only going to get on initial scans because it can help us in risk stratifying patient's and help us decide whether we're gonna treat a patient.

we're not gonna be monitoring TBS over time. there's a lot of interest in using TBS to look at response to treatment. there's been a few studies that looked at TBS changes with the anabolic management, so if someone's on teriparatide or abaloparatide, TBS can improve. in patient's on antiresorptive therapy, so Reclass or Fosamax or bisphosphonates, we don't really see a change in TBS values.

So in the future we might be using TBS to monitor treatment, anabolic therapy. response.

Melanie Cole (Host): Doctor, if you were advising organizations like the National Osteoporosis Foundation today, would TBS integration be something that you would advise them use in clinical pathways? Would it be a recommendation or a mandate? What would you advise?

Dr Basma Abdulhadi: I think it's very useful, to use TBS because, it provides complimentary but actually independent information about fracture risk assessments. So the best thing to do is to combine both parameters to get a more comprehensive view of the patient's bone health. So, BMD and TBS are complementary. They both provide valuable information.

TBS is going to be very important in patient's who are borderline cases where the patient's fracture risk estimate puts them at the threshold of treatment. in these situations, TBS will be very important because it might reclassify patient's either above or below the treatment threshold. So, it might help you make a decision to start patient on therapy versus.

Holding off and monitoring. So I think that's really where it adds a lot of value in these borderline cases. and it can really help drive management decisions. I will say it should not be used alone for diagnosis. So if someone has a low BS score, we can't really use that to say, okay, we're gonna start the patient on therapy.

But I think. When we use it in addition to BMD, it's gonna provide a lot of valuable information. I don't think we've talked about the numbers of TBS. Again, TBS is unitless, so it's just gonna be a number that shows up. Anything above 1.3 is gonna be normal TBS value or normal bone micro architecture.

Anything less than 1.2 is considered degraded micro architecture. And then anything in between is partially degraded.

Melanie Cole (Host): Doctor, This is really an interesting prospect, this TBS And the implications for it. So what's the most important piece of clinician education that you feel we haven't nailed yet about tra bone score? The things that you wish every practitioner understood before they start using it.

Dr Basma Abdulhadi: I think one of the important things to remember is, tb s. Can independently predict fracture risk. It's been validated in multiple cohort studies and it can predict both vertebral and non-vertebral fracture. it is important to note that it can be used solidly or independently to diagnose osteoporosis, so we're still gonna rely on dexascan BMDT scores to diagnose osteoporosis.

It The best way to use TBS is to use it to complement BMD DEXA scan findings. So combining both parameters is gonna give us the best idea of the patient's, bone health. Most useful to use TBS and patient's with secondary osteoporosis. So again, it provides valuable information in patient's with type two diabetes patient's on steroids.

patient's with hyperparathyroidism and I think the most important clinical implication for FRAX adjusted TBS is really in patient's with borderline, cases where, you know, they're at the cusp of the threshold to initiate pharmacological therapy. in those patient's it might reclassify them as either above or below the treatment, threshold.

And, this might alter, clinical management.

Melanie Cole (Host): Thank you so much, Dr. Abdul Haddi for joining us today and, sharing so much great information for other providers. And for more information, you can always visit our website at uabmedicine.org/physician dot org slash physician. That concludes this episode of UAB MedCast. I'm Melanie Cole