Dr. LEE Joon Kiong

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• Dr. LEE Joon Kiong
• Malaysia

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Projected number of osteoporotic hip fractures
worldwide
742
378
Total number ofhip fractures1950 1.66
million 2050 6.26 million
Estimated no of hip fractures (1000s)
Adapted from Cooper C et al, Osteoporosis Int,
19922285-289
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WHO DETERMINES TREATMENT SUCCESS/FAILURE?

• Health care provider
• Health Care System
• Private versus public
• Doctors/Paramedics
• Physician/Surgeons/Nurses/Rehabilitation
• Pharmaceutical companies
• Cost
• Supportive programs

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WHO DETERMINES TREATMENT SUCCESS/FAILURE?

• Media
• Public
• Patients
• Family and carers

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• A Still Neglected Disease
• Ischemic heart disease
• Diabetes mellitus
• Cerebro-vascular disease
• AIDS
• ?????? OSTEOPOROSIS

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Health Care Provider Lack of Disease Awareness

• Public health program does not include
  osteoporosis
• Low priority
• Neglect the concept on skeletal health for all
  age groups
• Lack of driving force and support

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• Raising awareness about osteoporosis as a serious
  and debilitating disease
• Increasing the priority of osteoporosis at
  national health policy planning
• Urgently considering osteoporosis on the list of
  chronic, disabling diseases
• Define essential care levels at a national level
• Define future strategies, projects and plan to
  fight osteoporosis

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• To reduce the incidence of osteoporosis related
  fractures by promoting safe home environment for
  elderly
• Creating a national osteoporosis fracture
  database
• Considering subsidy for all proven therapies
  before fracture for individuals at high risk

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Health Care Provider Disease Awareness

• Programs on
• Prevention
• Identification of high risk individuals
• Early diagnosis
• Early and appropriate treatment intervention
• Prevention of fall
• Rehabilitation program for patients with fracture

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Doctors Disease Awareness

• Disease awareness
• Priority
• Pro-active
• Physician treating patients for other medical
  conditions are more proactive in identifying
  underlying osteoporosis
• High risk groups
• To assess fracture risks

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Doctors Disease Awareness

• Diagnosis
• To initiate and suggest diagnostic measurement
  (DXA) to patients
• Combined approach (Surgeon Physician)
• Education
• Pharmacological intervention
• to offer appropriate treatment if indicated
• to monitor treatment

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Osteoporosis Self-assessment Tool for Asia (OSTA)
Weight (kg)
LOW RISK
Age (yr)
AT RISK measure BMD
HIGH RISK measure BMD treat
History of prior non-violent fracture consider
BMD measurement and treatment
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• Assist decision making
• Assist selection of appropriate treatment
• Algorithm

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Operate and send home!
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• Post-operative care
• Ambulation and weight bearing

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• 1162 women, all greater than 65 year of age and
  treated for distal radial fractures, coming from
  22 states throughout the United States
• Only 2.8 were sent for bone density testing to
  evaluate and document the presence of
  osteoporosis
• Only 22.9 of the women with fractures received
  any subsequent anti-osteoporosis medical treatment

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• 227 postmenopausal women were admitted with a
  low-impact fracture (hip, spine, wrist, or
  humerus) to a hospital in Minnesota, osteoporosis
  was considered in only 26.
• Within 12 months of discharge, only 10 had
  undergone BMD testing and only 26 were
  prescribed osteoporosis treatment.

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• Only 5 of 343 postmenopausal women admitted with
  a minimal trauma forearm fracture underwent bone
  density measurement in the subsequent 12 months.
• Only 18 were administered any intervention
  during the year after fracture.

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Elderly men with fragility fractures were
virtually ignored (1, 2) even though it is known
that men have a higher mortality rate than women
in acute care after hip fracture .
1. Juby AG, De Geus-Wenceslau CM 2002 Evaluation
of osteoporosis treatment in seniors after hip
fracture. Osteoporos Int 13205210
2. Kiebzak GM, Beinart GA, Perser K, Ambrose CG,
Siff SJ, Heggeness MH 2002 Undertreatment of
osteoporosis in men with hip fracture. Arch
Intern Med 16222172222
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• Osteoporosis was also less likely to be sought in
  elderly patients, even though anti- resorptive
  therapy is known to reduce fracture risk in the
  very oldest patients .

Onder G, Pedone C, Gambassi G, Landi F, Cesari
M, Bernabei R, Investigators of the GIFA Study
2001 Treatment of osteoporosis among older adults
discharged from hospital in Italy. Eur J Clin
Pharmacol 57599604
Klotzbuecher CM, Ross PD, Landsman PB, Abbott
III TA, Berger M 2000 Patients with prior
fractures have an increased risk of future
fractures a summary of the literature and
statistical synthesis. J Bone Miner Res
15721739
Colon-Emeric CS, Sloane R, Hawkes WG,
Magaziner J, Zimmerman SI, Pieper CF, Lyles KW
2000 The risk of subsequent fractures in
communitydwelling men and male veterans with hip
fracture. Am J Med 109324326
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• NO TREATMENT!!!!!!
• Patient Factors
• Osteoporosis?
• Default follow up
• Physician/Surgeon Factors
• Attitude Not interested, Who cares?, So What?
• Awareness
• Busy practice
• Lack of physician-surgeon collaboration

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• Orthopedic surgeons treating low trauma
  fractures in postmenopausal women and older men
  need to take the next step
• to initiate an evaluation for osteoporosis
  themselves or
• to refer the patient back to the primary care
  physician or
• to a medical specialist with a specific request
  for evaluation and appropriate treatment.

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• Physiotherapists, nurses etc should identify
  patients with clinical features of fracture and
  refer to physicians/surgeon for further
  evaluation
• to educate and encourage patients and family
• to maintain physical activities to minimize fall
• to tailor rehabilitation program for individual
  patient to maximize their functional recovery

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• Public health problem
• Silent disease
• Early diagnosis for high
• risk individuals
• The need for long term
• therapy
• Reduction of fracture
• risk

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Patient - Treatment

• Acceptable
• Understand the need for long term treatment
• Available
• Different classes of therapeutic agents
• Accessible
• Both in urban and rural areas
• Affordable
• Cost for long term treatment

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• Stimulators of bone formation
• (Fluoride)
• Parathyroid hormone
• Mixed mechanism of action
• Vitamin D and metabolites
• Strontium ranelate
• For All Patients
• Calcium and vitamin D

• Inhibitors of bone resorption Bisphosphonates
• Alendronate
• Risedronate
• Ibandronate
• Zoledronate
• Calcitonin
• Estrogen progestin
• (SERMs)
• Raloxifene

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• Daily
• Alendronate 10mg
• Strontium ranelate 2gm
• Raloxifene 60mg
• Weekly
• Alendronate 70mg, Alendronate Plus 70 mg
• Risedronate 35mg
• Monthly
• Ibandronate
• Yearly
• Zoledronate

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Patient Treatment Monitoring

• Just like hypertension, diabetes mellitus and
  other medical conditions
• Why monitor?
• Improve adherence and compliance
• Translate into effective treatment outcome
• Reduction of fracture risks

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Patients Show Poor Persistence
Why Monitoring? NDC Health Study Poor
Persistence even with Weekly Prescriptions
A HIPAA-compliant, longitudinal patient database
of prescriptions dispensed from 25 of US retail
pharmacies was used to assess discontinuation of
bisphosphonates over a 12-month period in women
aged 50 years. Primary usage in
osteoporosis however, data may include use in
other indications.

• Ettinger M, et al. Arthritis Rheum.
  200450(suppl)S513-S514. Abstract 1325.
• Data on file (Reference 161-040), Hoffmann-La
  Roche Inc., Nutley, NJ 07110.

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Monitoring Improves Compliance
The Impact of Monitoring on Adherence and
Persistence
The Kaplan-Meier survival curves for cumulative
adherence to therapy (75) are shown for the
monitored group (nurse-monitoring and
marker-monitoring) compared to the no monitoring
group. Monitoring increased cumulative
adherence to therapy (75) by 57 compared with
no monitoring (P 0.04). There was a trend for
greater cumulative adherence to therapy in the
nurse-monitoring and marker-monitoring groups (P
0.05 and P 0.15) compared to usual cure.
Source Clowes et al (2004) The Journal of
Clinical Endocrinology Metabolism
89(3)1117-1123
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Patient Treatment Monitoring

• Monitoring Techniques
• Acceptable
• Available
• Accessible
• Affordable
• Clinical
• Radiological
• DXA scan
• Bone turnover markers

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Patient Treatment Monitoring

• DXA
• BMD changes with pharmacological
• agents only explain partially the
• reduction of fracture risk
• Significant changes seen only
• after 1 ½ to 2 years of treatment

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Patient Treatment Monitoring

• Bone turnover markers
• As early as three months after
• treatment with anti-resorptive agents

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Patient Treatment Monitoring

• Bone turnover markers
• Limitations
• Not readily available in Asian countries
• More important role in clinical practice
• Baseline, three months and nine months after
  treatment

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Public Patient Society
Persatuan Kesedaran Osteoporosis Kuala Lumpur
(Osteoporosis Awareness Society of Kuala Lumpur)
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Public Patient Society

• Promoting skeletal health in public throughout
  all age groups
• Public awareness on osteoporosis
• Identification of at risk group
• Diagnosis
• Treatment
• Patient support group
• Patients with and without fractures
• Carers

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Public Patient Society

• Patient and family should play the primary role
  in promoting treatment uptake
• Supervise patients the correct way of taking
  their medicines
• Ensure compliance and adherence
• Safe home environment

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Health Care Providers
Doctors/Paramedics
Patients/Public
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Thank You