Osteoporosis: Miller PD

Watts NB, Lewiecki EM, Miller PD, Baim S. · No affiliation provided · J Clin Densitom. · Pubmed #18562228 No free full text.

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Krieg MA, Barkmann R, Gonnelli S, Stewart A, Bauer DC, Del Rio Barquero L, Kaufman JJ, Lorenc R, Miller PD, Olszynski WP, Poiana C, Schott AM, Lewiecki EM, Hans D. · Lausanne University Hospital, Lausanne, Switzerland. <> · J Clin Densitom. · Pubmed #18442758 No free full text.

Abstract: Dual-energy X-ray absorptiometry (DXA) is commonly used in the care of patients for diagnostic classification of osteoporosis, low bone mass (osteopenia), or normal bone density; assessment of fracture risk; and monitoring changes in bone density over time. The development of other technologies for the evaluation of skeletal health has been associated with uncertainties regarding their applications in clinical practice. Quantitative ultrasound (QUS), a technology for measuring properties of bone at peripheral skeletal sites, is more portable and less expensive than DXA, without the use of ionizing radiation. The proliferation of QUS devices that are technologically diverse, measuring and reporting variable bone parameters in different ways, examining different skeletal sites, and having differing levels of validating data for association with DXA-measured bone density and fracture risk, has created many challenges in applying QUS for use in clinical practice. The International Society for Clinical Densitometry (ISCD) 2007 Position Development Conference (PDC) addressed clinical applications of QUS for fracture risk assessment, diagnosis of osteoporosis, treatment initiation, monitoring of treatment, and quality assurance/quality control. The ISCD Official Positions on QUS resulting from this PDC, the rationale for their establishment, and recommendations for further study are presented here.

Khan AA, Hanley DA, Bilezikian JP, Binkley N, Brown JP, Hodsman AB, Josse RG, Kendler DL, Lewiecki EM, Miller PD, Olszynski WP, Petak SM, Syed ZA, Theriault D, Watts NB, Anonymous00369. · Division of Endocrinology, McMaster University, Hamilton, Ontario, Canada, and Hanover General Hospital, PA, USA. · J Clin Densitom. · Pubmed #16731431 No free full text.

Abstract: This document addresses skeletal health assessment in individuals with secondary causes of osteoporosis. Recommendations are based on consensus of the Canadian Panel of the International Society for Clinical Densitometry and invited international experts. Bone mineral density (BMD) testing in these populations is performed in conjunction with careful evaluation of the disease state contributing to bone loss and increased fragility fracture risk, as well as assessment of other contributing risk factors for fracture. The presence of secondary causes of bone loss may further increase the risk of fracture independently of BMD and may necessitate earlier pharmacologic intervention. Dual-energy X-ray absorptiometry is indicated in the initial workup of secondary causes of osteoporosis. The BMD fracture risk relationship is not known for individuals with chronic renal failure (CRF). The BMD testing in this population may be normal in the presence of skeletal fragility, and quantitative bone histomorphometry is better at evaluating skeletal status than BMD in CRF. Dual-energy X-ray absorptiometry is a valuable tool in assessing skeletal health in individuals with secondary causes of osteoporosis.

Khan AA, Bachrach L, Brown JP, Hanley DA, Josse RG, Kendler DL, Leib ES, Lentle BC, Leslie WD, Lewiecki EM, Miller PD, Nicholson RL, O'Brien C, Olszynski WP, Theriault MY, Watts NB, Anonymous00235. · Divisions of Endocrinology and Geriatrics, McMaster University, Hamilton, ON, Canada. · J Clin Densitom. · Pubmed #14742888 No free full text.

Abstract: The Canadian Panel of the International Society for Clinical Densitometry has developed standards in order to establish the minimum level of acceptable performance for the practice of bone densitometry in Canada. Previously, this group addressed the performance of densitometry in postmenopausal women. This report addresses the use of densitometry in men, premenopausal women, and children with a focus on dual-energy X-ray absorptiometry.

Khan AA, Brown J, Faulkner K, Kendler D, Lentle B, Leslie W, Miller PD, Nicholson L, Olszynski WP, Watts NB, Anonymous00159. · McMaster University, Oakville, Ontario, Canada. · J Clin Densitom. · Pubmed #12665644 No free full text.

Abstract: The International Society for Clinical Densitometry (ISCD) is a multidisciplinary nonprofit global organization formed to ensure excellence in densitometry imaging, interpretation, and application. The Canadian panel of the ISCD represents ISCD in Canada and oversees Canadian bone densitometry certification programs. The standards of care from the Canadian panel of the ISCD have been developed in order to establish the minimum level of acceptable performance for the practice of bone densitometry in Canada. A variety of techniques are available for skeletal assessment of bone mineral density, which vary in accuracy, precision, and clinical utility as well as availability. This article focuses on central dual X-ray absorptiometry in adults and does not address densitometry in the pediatric population. Other technologies will be addressed in a subsequent article.

Miller PD. · No affiliation provided · J Clin Densitom. · Pubmed #18442748 No free full text.

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Miller PD. · No affiliation provided · J Clin Endocrinol Metab. · Pubmed #12574176 links to  free full text

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Miller PD. · No affiliation provided · Calcif Tissue Int. · Pubmed #10773098 No free full text.

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Miller PD. · University of Colorado Health Sciences Center, Colorado Center for Bone Research, Lakewood, CO 80227, USA. · Semin Nephrol. · Pubmed #19371805 No free full text.

Abstract: Osteoporosis is the most prevalent metabolic bone disease leading to low-trauma (fragility) fractures worldwide. There is no reason why osteoporosis, as defined by different criteria, cannot accompany the derangements in bone metabolism that characterize chronic kidney disease (CKD). In fact, osteoporosis could and should be included in the broad characterization of CKD-mineral and bone disorder (CKD-MBD), as recently proposed by the Kidney Disease: Improving Global Outcomes working group. The pathophysiology leading to osteoporosis or CKD-MBD shares many common yet distinctly different pathways. Both pathways may lead to impairment of bone strength and low-trauma fractures. The challenge for clinical practice is how to discriminate between osteoporosis and CKD-MBD in fracturing patients. There is agreement that in the absence of aberrant biochemical tests suggesting CKD-MBD in stages 1 through 3 CKD, osteoporosis can be diagnosed using the World Health Organization criteria or development of low-trauma fractures. The distinction between osteoporosis and CKD-MBD becomes more difficult in stages 4 and 5 through 5D CKD. In fracturing patients with these levels of severe CKD, careful biochemical assessment of bone turnover markers and, in selected cases, bone biopsy is needed to eliminate CKD-MBD and to diagnose osteoporosis by exclusion. In stages 1 through 3 CKD, the current registered osteoporosis pharmacologic therapies can be used to treat osteoporosis. In stage 4, 5, and 5D these agents can be considered off-label, but only after very careful considerations and only in fracturing patients without CKD-MBD. We need better noninvasive means of discriminating among all these metabolic bone diseases and prospective data to guide us to the use of agents that alter bone remodeling in high-risk patients with more severe CKD.

Baim S, Miller PD. · Colorado Center for Bone Research, Lakewood, Colorado 80227, USA. · J Bone Miner Res. · Pubmed #19257812 No free full text.

Abstract: Bone turnover markers (BTMs) have become increasingly important in the management of postmenopausal osteoporosis (PMO). In bisphosphonate-treated women with PMO, BTMs can provide early indications of treatment efficacy, are predictors of BMD response and fracture risk reduction, and are potentially useful for monitoring patient compliance. The bone resorption marker serum C-telopeptide cross-link of type 1 collagen (sCTX) has shown high sensitivity and specificity for the detection of increased bone resorption. Recently, sCTX has been singled out as a potential indicator of risk of osteonecrosis of the jaw (ONJ) in patients receiving oral bisphosphonates who require oral surgery. However, whether BTMs are capable of predicting ONJ risk and whether sCTX is usable for this purpose are controversial questions. This article presents an overview of the current literature regarding critical issues affecting the clinical utility of BTMs (including variability and reference ranges) and the current applications of BTMs in PMO management, with a focus on sCTX. Last, the appropriateness of using sCTX to predict ONJ risk in women receiving oral bisphosphonates for PMO is evaluated.

Miller PD. · Department of Medicine, University of Colorado Health Sciences Center, Colorado Center for Bone Research, 3190 South Wadsworth Boulevard, Lakewood, CO 80227, USA. · Curr Osteoporos Rep. · Pubmed #19239825 No free full text.

Abstract: Denosumab (anti-receptor activator of nuclear factor-kappaB ligand antibody) is a novel agent, a fully human monoclonal antibody that inhibits osteoclastic-medicated bone resorption by binding to osteoblast-produced RANKL. By reducing RANKL binding to the osteoclast receptor RANK, bone resorption and turnover decrease. In phase 2 dose-ranging studies, denosumab had a rapid onset and offset effect. Also, in patients who had received 2 years of denosumab and were discontinued for the third year, rechallenge with denosumab during the fourth year demonstrated a return of responsiveness to denosumab that mimicked the initial treatment. Phase 3 pivotal fracture data were recently presented with positive outcome data; denosumab (60 mg subcutaneously every 6 months) significantly reduced vertebral, nonvertebral, and hip fracture risk compared with placebo, and had an excellent safety profile through 3 years of use. Denosumab will offer a novel approach to managing postmenopausal osteoporosis, one that should be associated with a high adherence rate and global fracture risk reduction.

Miller PD, Ward P, Pfister T, Leigh C, Body JJ. · Colorado Center for Bone Research, Lakewood, Colorado, USA. · Clin Exp Rheumatol. · Pubmed #19210886 No free full text.

Abstract: While intravenous (IV) bisphosphonates are well established in managing metastatic bone disease and hypercalcemia of malignancy, oral bisphosphonates are the primary treatment for postmenopausal osteoporosis. The availability of a well-tolerated, effective, IV bisphosphonate regimen for postmenopausal osteoporosis would increase physicians' options, allowing treatment of patients who cannot tolerate oral therapy, for whom oral bisphosphonates should be avoided or patients who are unable to comply with the oral dosing recommendations. Ibandronate is a potent, nitrogen-containing bisphosphonate, with proven efficacy and good tolerability when administered intermittently either orally or intravenously. Preclinical experience in animal models with IV ibandronate indicated that it had good renal tolerability. These data are supported by clinical pharmacology studies. Prolonged follow-up of patients receiving intermittent IV 15-30 second injections of 0.5-3 mg IV ibandronate has demonstrated no clinical evidence of renal toxicity in patients with postmenopausal osteoporosis. What is seen in controlled studies is not always the case in uncontrolled studies, however, no reports of renal failure have been received in post-marketing surveillance of >500,000 patients receiving IV ibandronate infusions in various indications including metastatic breast and prostate cancer. The good renal tolerability of IV ibandronate in patients with osteoporosis with glomerular filtration rates >30 mL/minute and without renal co-morbid conditions is reassuring.

Recker RR, Lewiecki EM, Miller PD, Reiffel J. · School of Medicine, Creighton University, Omaha, Nebraska, USA. · Am J Med. · Pubmed #19187809 No free full text.

Abstract: In this review 4 experts consider the major safety concerns relating to bisphosphonate therapy for osteoporosis. Specific topics covered are skeletal safety (particularly with respect to atypical fractures and delayed healing), gastrointestinal intolerance, hypocalcemia, acute-phase (i.e., postdose) reactions, chronic musculoskeletal pain, renal safety, and cardiovascular safety (specifically, atrial fibrillation).

Miller PD. · Colorado Center for Bone Research, Lakewood, Colorado 80227, USA. · Best Pract Res Clin Endocrinol Metab. · Pubmed #19028360 No free full text.

Abstract: Bone-active agents that decrease bone turnover (the anti-resorptive agents) have been, to date, the most thoroughly studied pharmacological agents for the management of osteoporosis in a variety of populations - postmenopausal, male, and glucocorticoid-induced osteoporosis - and have received both Food and Drug Administration (FDA) and Committee for Medicinal Products for Human Use (CHMP) as well as other worldwide registrations for the management of these conditions. While the mechanisms of action of 'anti-resorptives' as a class differ, their effect on increasing bone strength and reducing the risk of fragility fractures share common pathways: an increase in bone mineral content, and a reduction in bone turnover. Within the category of anti-resorptives: estrogen, selective estrogen receptor modulators, tibolone, calcitonin, bisphosphonates and denosumab all reduce vertebral fractures risk, but differ in their ability to reduce the risk of non-vertebral fractures in randomized clinical trials. This chapter will discuss the data on these effects for each class of anti-resorptive agent.

Miller PD. · University of Colorado Health Sciences Center, Colorado Center for Bone Research, 3190 S. Wadsworth Boulevard, #250, Lakewood, CO 80227, USA. · Clin J Am Soc Nephrol. · Pubmed #18988699 No free full text.

Abstract: Renal bone disease is a heterogeneous group of metabolic bone diseases that requires quantitative bone histomorphometry to make the correct differential diagnosis. Included in this group is osteoporosis. However, osteoporosis in stage 4 to 5 chronic kidney disease cannot be diagnosed on the basis of bone mineral density criteria established by the World Health Organization or the presence of fragility fractures because patients with all forms of renal bone disease can demonstrate low bone mineral density and fragility fractures. Clinical cases in patients with either low bone mineral density and/or low-trauma fractures will be used to demonstrate the value of bone biopsy and quantitative histomorphometry in making a diagnosis of the specific renal bone disease and assisting with subsequent management decisions.

Miller PD. · Colorado Center for Bone Research, 3190 South Wadsworth Boulevard, Suite #250, Lakewood, CO 80227, USA. · Curr Osteoporos Rep. · Pubmed #18430395 No free full text.

Abstract: Teriparatide (recombinant human 1-34 parathyroid hormone) has been registered for the treatment of postmenopausal osteoporosis and osteoporosis in men for more than 5 years, whereas 1-84 parathyroid hormone has just recently been registered in Europe for osteoporosis management. Therefore, more data are available regarding the long-term safety of teriparatide. The issues to be considered are the effects of the registered dose of teriparatide (20 microg/day) on the incidence of hypercalcemia, hypercalciuria, and hyperuricemia, and the US Food and Drug Administration's "black-box" warning regarding osteogenic sarcoma in the rat model. This review discusses these issues and provides the author's extensive clinical experience and advice on the use of teriparatide in clinical practice.

Miller PD. · Colorado Center for Bone Research, Lakewood, CO 80227, USA. · Curr Med Res Opin. · Pubmed #18031594 No free full text.

Abstract: BACKGROUND: To license a therapy for the treatment of postmenopausal osteoporosis pharmacological agents must show ability to reduce the incidence of morphometric vertebral fractures versus placebo over a 3-year study period. In Europe, recent registration guidelines require evidence of reduction of vertebral and non-vertebral fracture incidence over a minimum of 2 years compared with placebo. There is much interest in the prevention of non-vertebral fractures. While morphometric vertebral fractures are assessed and statistically powered as the registration primary endpoint in clinical trials, non-vertebral fractures are often measured as secondary endpoints or captured as adverse events, which have selection biases in data capturing. AIM: To describe factors that influence fracture risk and the rate of osteoporotic non-vertebral fractures observed in randomized controlled studies of the oral nitrogen-containing bisphosphonates licensed for the treatment of postmenopausal osteoporosis (alendronate, risedronate and ibandronate). METHODS: A literature search was conducted using PubMed and ISI Web of Knowledge and using keywords representing drug names and trial types. Results were screened using selection criteria based on trial type and vertebral fracture endpoint of trials published from 1990 to 2007. Findings and conclusion: Without comparative head-to-head antifracture studies, current evidence does not support a clear differentiation in fracture reduction among the different bisphosphonates. The rate of fracture in a clinical study is dependent on different factors (e.g., skeletal fragility), which may vary from study to study. Even in trials assessing non-vertebral fractures as a primary endpoint, differences in study design, randomized population and varying definitions of what constitutes a non-vertebral fracture can influence outcomes. In addition, falls and fall-related risk factors have never been controlled for in or between individual studies. Although etidronate, administered with an extended between-dose interval, has demonstrated a significant reduction in fracture risk, this was in a subgroup population, with the addition of phosphate or when only data from weeks 61-150 of the study were included in the analysis. None of the remaining currently registered non-daily oral bisphosphonates have prospective fracture data, and have, therefore, been registered on the basis of non-inferiority (surrogate marker bone mineral density and bone turnover marker) endpoints. However, a lack of evidence, if the appropriately designed studies have not been completed, does not necessarily indicate a lack of efficacy. Such a conclusion can only be drawn if a suitable study has been completed that definitively shows a lack of effect on non-vertebral fractures.

Lewiecki EM, Miller PD. · University of New Mexico School of Medicine, Albuquerque, New Mexico, USA. · Expert Opin Drug Saf. · Pubmed #17967155 No free full text.

Abstract: Oral bisphosphonates are the mainstay of treatment for osteoporosis but cannot be used in some patients due to gastrointestinal contraindications, gastrointestinal intolerance, malabsorption or the inability to comply with dosing requirements. In such patients, intravenous bisphosphonates are a useful alternative. This review summarises the renal safety issues associated with the use of intravenous bisphosphonates for osteoporosis. Intravenous bisphosphonates are generally well tolerated, which may be a reflection of their selective activity in bone and metabolic stability. Adverse effects on renal function are primarily related to infusion rate and dose. Due to lack of data, no conclusions can be made regarding bisphosphonate safety in patients with intrinsic renal disease or an estimated glomerular filtration rate of < 30 ml/min.

Miller PD. · Department of Medicine, University of Colorado Health Sciences Center, Denver, Colorado, USA. · Semin Dial. · Pubmed #17555478 No free full text.

Abstract: Patients with stage 5 chronic kidney disease (CKD) including those on dialysis can and do develop osteoporosis. They also develop a wide range of other metabolic bone diseases that may look like osteoporosis when it is defined by either the World Health Organization bone mineral density (BMD) criteria or by the development of fragility fractures. Those dialysis patients with osteoporosis that is due to gonadal hormone deficiency such as postmenopausal osteoporosis, glucocorticoid-induced osteoporosis, or male osteoporosis may benefit from the administration of bisphosphonates (BPs). The challenges lie in the diagnosis of osteoporosis in this population where adynamic, osteomalacic, hyperparathyroid, or aluminum bone disease are also prevalent, with concommitant low BMD and low trauma fractures, but where BPs may be contraindicated. The only secure means to diagnose osteoporosis in this patient population is by quantitative bone histomorphometry demonstrating low trabecular bone volume and disrupted microarchitecture. Once the diagnosis of osteoporosis is established, BPs should be considered for a well-defined brief period of time (e.g., 2-3 years), even though there is no evidence for a fracture reduction benefit in this population. If a BP is chosen there may be a need for dose adjustment or slower infusion rates (for the intravenous formulations), as a greater bone retention may occur for these renally cleared agents. While it is unknown what consequences could develop from increased bone retention in patients with little renal function, data are needed if more bone retention of BP might lead to a greater risk of the development of adynamic bone disease and lower bone strength. More data are needed to define the risks and benefits of BPs in patients with stage 5 CKD.

Miller PD. · University of Colorado Health Sciences Center, Colorado Center for Bone Research, Lakewood, CO, USA. · Rev Endocr Metab Disord. · Pubmed #17186388 No free full text.

Abstract: The development of bone mineral densitimometry methodologies, especially central dual energy X-ray absorptiometry (DXA) methods have allowed this quantitative tool to be used to diagnose osteoporosis before the first fragility fracture has occurred. The World Health Organization osteoporosis working group set the stage for the BMD cut-off criteria development. The wide application of DXA has brought the treatment of osteoporosis to the primary care level, a very necessary step if this increasingly prevalent disease is to have a decline in its incidence. The most difficult osteoporosis cases, for which there are many and their associated difficult DXA results and interpretation will always require specialists' involvement. In particular, the embracement of the WHO absolute fracture risk validated project will take DXA to a much greater level of value in making management decisions. In particular, the WHO absolute risk data will allow physicians, health-economic policy makers, and payors of medical services to come closer together to decide which patients are at a level of unacceptable fracture risk that justifies treatment intervention. The implementation of this validated project will also remove the unacceptable subjective computer printouts on DXA reports that often lead to the over-treatment of low risk patients and at times the under-treatment of high risk patients. The evolution of the clinical interpretation of bone densitometry has been a work in progress. Challenges in the clinical measurement of bone strength remain and will also evolve. The field of osteoporosis has grown with the use of DXA and will continue to embrace this technology as other technologies to measure fracture risk become applied in clinical practice.

Lewiecki EM, Richmond B, Miller PD. · New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA. · Cleve Clin J Med. · Pubmed #16913198 links to  free full text

Abstract: Quantitative ultrasonography is attractive as a test for osteoporosis, being precise, radiation-free, portable, and inexpensive, but it is still no substitute for the gold-standard test, dual-energy x-ray absorptiometry (DXA). At present, it cannot be used to diagnose osteoporosis or to monitor the effects of medications on bone density. As more data become available, however, it may play a larger role. A thorough understanding of the utility and limitations of this test is necessary for using it effectively in clinical practice.

Miller PD. · Colorado Center for Bone Research, Lakewood, Colorado 80227, USA. · Int J Fertil Womens Med. · Pubmed #16334416 No free full text.

Abstract: More postemenopausal women with osteopenia fracture than those who have osteoporosis. Algorithms are being developed to enhance risk stratification to facilitate decisions when to treat in the osteopenic population. Evidence exists that osteoporosis agents can reduce fracture risk in the osteopenic population.

Miller PD. · Colorado Center for Bone Research, 3190 S. Wadsworth Blvd, Lakewood, CO 80227, USA. · Curr Osteoporos Rep. · Pubmed #16131430 No free full text.

Abstract: Surrogate markers in clinical medicine provide a useful means to assess therapeutic response to pharmacologic therapy in a wide range of chronic disease states. In the area of osteoporosis, the surrogate markers of change in bone mineral density (BMD) and bone turnover markers (BTM) provide the clinician with a means of assessing the biologic response to osteoporosis-specific pharmacologic agents. Increases in BMD and/or reductions in BTM can independently be correlated to reductions in vertebral and nonvertebral fracture risk. In managing osteoporosis patients, the BTM change at an earlier point of time after initiation of therapy and a change in BTM can provide earlier feed-back to the patient and clinician regarding issues such as compliance and a bone biologic response. An increase in BMD at 12 or 24 months after initiation of therapy is also evidence of an improvement in bone strength though with antiresorptive agents no change in BMD may also be associated with risk reduction within clinical trial sets. In this regard, changes in BMD and BTM are complimentary in their application to patient management.

Miller PD. · Colorado Center for Bone Research, 3190 South Wadsworth #250, Lakewood, CO 80227, USA. · Curr Osteoporos Rep. · Pubmed #16036095 No free full text.

Abstract: As glomerular filtration rate (GFR) declines from age-related bone loss or disease that specifically induces a decline in GFR, there are a number of metabolic bone conditions that may accompany the decline in GFR. These metabolic bone conditions span a spectrum from mild-to-severe secondary hyperparathyroidism in early stages of chronic kidney disease (CKD) to the development of additional heterogeneous forms of bone diseases each with its distinctly quantitative bone histomorphometric characteristics. Osteoporosis can also develop in patients with CKD and ESRD for many reasons beyond age-related bone loss and postmenopausal bone loss. The diagnosis of osteoporosis in patients with severe CKD or end-stage renal disease (ESRD) is not as easy to do as it is in patients with postmenopausal osteoporosis (PMO)--neither fragility fractures nor The World Health Organization bone mineral density criteria can be used to diagnose osteoporosis in this population since all forms of renal bone disease may fracture or have low "T scores". The diagnosis of osteoporosis in patients with CKD/ESRD must be done by first the exclusion of the other forms of renal osteodystrophy, by biochemical profiling or by double tetracycline-labeled bone biopsy; and the finding of low trabecular bone volume. In such patients, preliminary data would suggest that oral bisphosphonates seem to be safe and effective down to GFR levels of 15 mL/min. In patients with stage 5 CKD who are fracturing because of osteoporosis or who are on chronic glucocorticoids, reducing the oral bisphosphonate dosage to half of its usual prescribed dosing for PMO seems reasonable from known bisphosphonate pharmacokinetics, though we do need better scientific data to fully understand bisphosphonate usage in this population.

Miller PD. · Colorado Center for Bone Research, 3190 S. Wadsworth Blvd, Lakewood, CO 80227, USA. · Curr Osteoporos Rep. · Pubmed #16036084 No free full text.

Abstract: Bone mineral density (BMD) measurements have been the single greatest advancement for osteoporosis. BMD measurements have helped define a prefracture diagnosis of osteoporosis, predict fracture risk in postmenopausal women and elderly men, and monitor the course of disease processes that negatively affect bone or therapeutic agents that can improve bone strength. Despite the large amount of clinical, epidemiologic, and basic science data that has advanced our understanding of BMD performance and interpretation, many pitfalls in BMD performance and interpretation pervade the practice of bone densitometry. However, all of these pitfalls can be overcome. Proper quality control and clinical interpretation of BMD computer printout reports are paramount for correct diagnosis, risk assessment, and serial BMD measurements. Though BMD application(s) are a clinical tool that can and should be used by many different primary care and specialty physicians, the performances and interpretations are not simple processes. Proper education and training in the use of BMD technologies provides the means of achieving the great intent that BMD measurements are capable of providing.