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Osteoporosis: Measuring the Problem

Osteoporosis: Measuring the Problem. Dr. Tuan V. Nguyen Associate Professor Bone and Mineral Research Program Garvan Institute of Medical Research Sydney, Australia. Measuring osteoporotic fractures. Magnitude of the problem Consequences Undertreated, underdiagnosed and what to do?.

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Osteoporosis: Measuring the Problem

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

  2. Measuring osteoporotic fractures • Magnitude of the problem • Consequences • Undertreated, underdiagnosed and what to do?

  3. Increase in life expectancy WHO. Human Population: Fundamentals of Growth World Health, 2000.

  4. The ageing of population Percent of population aged 65+ ABS and US Bureau of Census, 1996.

  5. 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 285:785-95; 2001)

  6. 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

  7. BMD and fracture T < 2.5 osteoporosis

  8. 14-year risk of fractures in WOMEN aged 60+ 1287women Osteoporosis 345 (27%) Non-osteoporosis942 (73%) Fx = 137 (40%) No Fx = 208 (60%) Fx = 191 (20%) No Fx = 751 (80%) 42%

  9. 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%) Fx = 91 (12%) No Fx = 640 (88%) 23%

  10. Magnitude of the Problem

  11. Incidence of all-limb fractures

  12. Annual fracture incidence in Australia 1996-2051 Projected annual number of all-limb fractures in Australia aged 35+ (Sanders et al, MJA 1999)

  13. Hip, vertebrae, and Colles fractures Projected annual number of all-limb fractures in Australia aged 35+(Sanders et al, MJA 1999)

  14. 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)

  15. 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)

  16. Ten-year and lifetime risk of fractures 10-y risk Lifetime risk with advancing age with advancing age

  17. Ten-year and lifetime risk of fractures Normal T-scores >-1.0 Osteopenia -2.5 < T-scores < -1.0 Osteoporosis T-scores < -2.5 Lifetime risk Age free-of-fracture (y) 10-y risk Age free-of-fracture (y)

  18. Ten-year and lifetime risk of any fracture by BMD and age

  19. Consequences of Osteoporotic Fractures

  20. Survival probability in thosewith and without fracture Nguyen et al, 2005

  21. 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

  22. 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

  23. 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

  24. Asymptomatic vertebral fracture increases risk of subsequent fractures 300 m+w 66 V # 234 No V # 29 Fx 37 no fx 180 no fx 54 Fx 44% 23% Pongchaiyakul C et al, J Bone Miner Res 2005

  25. Asymptomatic vertebral fracture increases risk of death 300 m+w 66 V # 234 No V # 20 deaths 46 survived 209 survived 25 deaths 30% 11% Pongchaiyakul C et al, J Bone Miner Res 2005

  26. 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

  27. Utility loss associated with fracture

  28. Under-treated & Under-diagnosis

  29. 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)

  30. 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)

  31. Levels of treatment in fractured women in primary care settings N = 20,248 Eisman JA, et al, J Bone Miner Res 2004

  32. Level of treatment in outpatients 157 low-trauma fx Prior fx: 76 No prior fx: 81 BMD: 18 (22%) Any Rx: 3 (10%) BMD: 35 (45%) Any Rx: 14 (18%) Bliuc D, et al, Osteoporosis Int 2004

  33. 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

  34. Risk factor modifications for fracture

  35. 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

  36. 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.

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