Osteoporosis:%20Measuring%20the%20Problem

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Osteoporosis Measuring the Problem
Dr. Tuan V. NguyenAssociate ProfessorBone and
Mineral Research ProgramGarvan Institute of
Medical ResearchSydney, Australia
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Measuring osteoporotic fractures

• Magnitude of the problem
• Consequences
• Undertreated, underdiagnosed and what to do?

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Increase in life expectancy
WHO. Human Population Fundamentals of Growth
World Health, 2000.
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The ageing of population
Percent of population aged 65
ABS and US Bureau of Census, 1996.
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Osteoporosis shift in definitions

• Low bone mass, microarchitectural deterioration
  of bone tissue leading to enhanced bone fragility
  and a consequent increase in fracture risk
  (Consensus Development Conference, 1991)

compromised bone strength predisposing a
person to an increased risk of fracture. Bone
strength primarily reflects the integration of
bone density and bone quality (NIH Consensus
Development Panel on Osteoporosis JAMA
285785-95 2001)
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Shift in thinking
RISK FACTOR
OUTCOME
Osteoporosis
Fracture
Bone Quality
Bone Mineral Density
Bone Strength
and
Architecture Turnover rate Damage
accumulation Degree of mineralization Properties
of the collagen/mineral matrix
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BMD and fracture
T lt 2.5 osteoporosis
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14-year risk of fractures in WOMEN aged 60
1287women
Osteoporosis 345 (27)
Non-osteoporosis 942 (73)
Fx 137 (40)
No Fx 208 (60)
No Fx 751 (80)
Fx 191 (20)
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14-year risk of fractures in MEN aged 60
821 men
Osteoporosis N 90 (11)
Non-osteoporosis 731 (89)
Fx 27 (30)
No Fx 63 (70)
No Fx 640 (88)
Fx 91 (12)
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Magnitude of the Problem
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Incidence of all-limb fractures
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Annual fracture incidence in Australia 1996-2051
Projected annual number of all-limb fractures in
Australia aged 35 (Sanders et al, MJA 1999)
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Hip, vertebrae, and Colles fractures
Fracture 2006 2051
Hip 20,700 60,000
Vertebrae 14,500 31,700
Colles 11,900 23,000
Humerus 7,500 16,300
Pelvis 4,100 9,800
Projected annual number of all-limb fractures in
Australia aged 35(Sanders et al, MJA 1999)
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Lifetime risk of some diseases - women
Any osteoporotic fracture Hip fracture Clinical
vertebral fracture Cancer (any site) Breast
cancer Lung/bronchus Coronary heart
diseases Diabetes Mellitus
, from birth
(from the age of 50)
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Lifetime risk of some diseases - men
Any osteoporotic fracture Hip fracture Clinical
vertebral fracture Cancer (any site) Prostate
cancer Lung/bronchus Coronary heart
diseases Diabetes Mellitus
, from birth
(from the age of 50)
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Ten-year and lifetime risk of fractures
10-y risk
Lifetime risk
? with advancing age
? with advancing age
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Ten-year and lifetime risk of fractures
Osteoporosis T-scores lt -2.5
Osteopenia -2.5 lt T-scores lt -1.0
Normal T-scores gt-1.0
Lifetime risk
Age free-of-fracture (y)
10-y risk
Age free-of-fracture (y)
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Ten-year and lifetime risk of any fracture by BMD
and age
FNBMD 10-year risk 10-year risk 10-year risk Lifetime risk Lifetime risk Lifetime risk
(T-score) Age free of fracture (y) Age free of fracture (y) Age free of fracture (y) Age free of fracture (y) Age free of fracture (y) Age free of fracture (y)
60 70 80 60 70 80
WOMEN WOMEN WOMEN WOMEN WOMEN WOMEN WOMEN WOMEN
gt -1.0 3.6 13.2 13.0 23.4 22.6 13.0
-2.4 to -1.1 25.4 25.3 25.7 55.7 44.3 33.0
? -2.5 35.8 40.1 42.3 72.2 64.9 54.8
MEN MEN MEN MEN MEN MEN MEN MEN
gt -1.0 9.7 7.6 15.1 25.1 18.4 15.1
-2.4 to -1.1 9.3 9.7 10.3 35.3 25.7 23.7
? -2.5 30.0 29.8 29.2 56.4 44.8 36.5
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Consequences of Osteoporotic Fractures
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Survival probability in thosewith and without
fracture
Nguyen et al, 2005
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Risk of death from hip fracture

• 50-year old women Lifetime risk of mortality
  from
• Hip Fracture 2.8
• Breast Cancer 2.8
• Endometrial Cancer 0.7

Cummings et al. Arch Intern Med 1989 149 2445-8
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Impact of hip fractures

• 25 die within 6 months ()
• 60 have restricted mobility ()
• 25 remain functionally more dependent
• Cardiac (8) and pumonary complication (4)
• Transient heart attacks
• Non-union and avancular necrosis

() Data from the Dubbo Osteoporosis Epidemiology
Study
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Impact of vertebral fractures

• Symptomatic fx Lifetime risk 1/4 women, 1/8 men
  
• Asymptomatic fx prevalence 20-30
• Back pain, functional limitation
• Rib-against-pelvis (RAP) syndrome
• Costoiliac impingement syndrome
• Decrease vital lung capacity

Pongchaiyakul C et al, J Bone Miner Res 2005
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Asymptomatic vertebral fracture increases risk of
subsequent fractures
300 mw
234 No V
66 V
29 Fx
37 no fx
180 no fx
54 Fx
44
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Pongchaiyakul C et al, J Bone Miner Res 2005
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Asymptomatic vertebral fracture increases risk of
death
300 mw
234 No V
66 V
20 deaths
46 survived
209 survived
25 deaths
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11
Pongchaiyakul C et al, J Bone Miner Res 2005
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Impact of wrist fracture

• More common in women in their 50s
• Post-traumatic arthritis
• Account for 39 of all physical therapy sessions
• Reduced daily living activies

Melton LJ, J Bone Miner Res 2003
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Utility loss associated with fracture
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Under-treated Under-diagnosis
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What the experts say?

• All women and men with a history of fragility
  fractures should be considered for treatment of
  osteoporosis to reduce their risk of future
  fracture. (Seeman and Eisman, MJA 2004)
• Initiate therapy to reduce fracture risk in
  postmenopausal women with BMD T-scores by DXA
  below -2 in the absence of risk factors and in
  women with T-scores below -1.5 if one or more
  risk factors are present. (NOF 2003)

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What the experts say?

• Recommend BMD testing to postmenopausal women
  who have suffered a fragility fracture to confirm
  the diagnosis and determine disease severity.
  (NOF 2003)

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Levels of treatment in fractured women in primary
care settings
N 20,248
Eisman JA, et al, J Bone Miner Res 2004
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Level of treatment in outpatients
157 low-trauma fx
Prior fx 76
No prior fx 81
BMD 35 (45)
Any Rx 14 (18)
BMD 18 (22)
Any Rx 3 (10)
Bliuc D, et al, Osteoporosis Int 2004
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Level of treatment experience in the US

• 502 hospitalised hip-fracture patients
• only 14 had BMD scans
• 13 received calcium and/or vitamin D
• 18 received HRT, calcitonin, or bisphosphonates.

Harrington JT, et al. Arthritis Rheum 2002 47
651-654
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Risk factor modifications for fracture
Intervention Estimated change in fx risk
Bisphosphonates, HRT, SERMs 30-50
Quit smoking -38
Treat impaired vision -50
Stop sedatives -40
Hip protectors -50?
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Summary

• In individuals aged 60 25 women and 11 men
  are osteoporosis (eg low BMD)
• Lifetime risk of fracture (from the age of 50)
  1/3 men and 1/2 women.
• With the presence of osteoporosis, lifetime risk
  increase to 1/2 men and 7/10 women

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Summary

• Fracture, particularly hip fracture, is a serious
  public health problem in the elderly.
• Increase mortality risk, reduced quality of life,
  incurred health care costs
• Osteoporosis is both under-treated and
  under-diagnosed.