2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada

1. 2010 Clinical PracticeGuidelines for the Diagnosis and Management of Osteoporosis in Canada Papaioannou A, et al. CMAJ 2010 Oct 12. [Epub ahead of print].

2. 2010 Guidelines Fragility Fracturesand Care Gaps Section Two

3. Fragility Fracture: Definition • A fracture occurring spontaneously or following minor trauma such as a fall from standing height or less1,2 • Excluding craniofacial, hand, ankle and foot fractures • Kanis JA, et al. Osteoporos Int 2001; 12(5):417-427. • Bessette L, et al. Osteoporos Int 2008; 19:79-86.

4. 95% 91.8% Overall: 81% 90% 85% 80% % of all fractures that are fragility fractures 75.7% 75% 70% 65% 60% 50-59 60-69 70-79 80+ Age groups The Majority of Fractures in Canadian Women > Age 50 Are Fragility Fractures Bessette L, et al. Osteoporos Int 2008; 19:79-86.

5. Consequences of Fracture • Increased risk of • Hospitalization/institutionalization1,2 • Death3-5 • Subsequent fracture6-8 • Decreased quality of life9-12 • Economic burden on healthcare system2 1. Papaioannou A, et al. Osteoporos Int 2001; 12(10):870-874. 2. Wiktorowicz ME, et al. Osteoporos Int 2001; 12(4):271-278. 3. Ioannidis G, et al. CMAJ 2009; 181(5):265-271. 4. Papaioannou A, et al. J SOGC 2000; 22(8):591-597. 5. Tosteson AN, et al. Osteoporos Int 2007; 18(11):1463-1472. 6. Papaioannou A, et al. J SOGC 2000; 22(8):591-597. 7. Colon-Emeric C, et al. Osteoporos Int 2003; 14:879-893. 8. Lindsay R, et al. JAMA 2001; 285:320-323. 9. Sawka AM, et al. Osteoporos Int 2005; 16:1836-1840. 10. Cranney A, et al. J Rheumatol 2005; 32(12):2393-2399. 11. Pasco JA, et al. Osteoporos Int 2005; 16(12):2046-2052. 12. Papaioannou A, et al. Osteoporos Int 2009; 20(5):703-715.

6. Impact on Function and Quality of Life • Loss of confidence and fear of falling have been reported with all types of fractures • < 40% of those who experience a hip fracture return to their prior walking abilities1,2 • Clinical fractures negatively affect self-care and mobility, and are associated with chronic pain3 1. Cranney A, et al. J Rheumatol 2005; 32(12):2393-2399. 2. Pasco JA, et al. Osteoporos Int 2005; 16(12):2046-2052. 3. Papaioannou A, et al. Osteoporos Int 2009; 20(5):703-715.

7. Undertreatment of Osteoporosis Post Fracture in Women1 This care gap is even wider in men and those who reside in long-term care2,3 A fracture is to osteoporosis what a heart attack is to cardiovascular disease. BUT... The treatment gap is far wider post fracture than post MI.1,4 1. Bessette L, et al. Osteoporos Int 2008; 19:79-86. 2. Papaioannou A, et al. Osteoporos Int 2008; 19(4):581-587. 3. Giangregorio L, Osteoporos Int 2009; 20(9):1471-8. 4. Austin PC, et al. CMAJ 2008; 179(9):901-908.

8. Looking Beyond BMD • Currently, low BMD is the primary trigger for initiation of therapy1-5. . . HOWEVER, • Most fragility fractures occur in those with a BMD in the non-osteoporotic range (T-score higher than -2.5)6 There is a missed opportunity to prevent future fractures due to over-reliance on BMD.6,7 1. Bessette L, et al. Osteoporos Int 2008; 19:79-86. 2. Papaioannou A, et al. BMC Musculoskelet Disord 2004; 5:11. 3. Elliot-Gibson V, et al. Osteoporos Int 2004; 15:767-778. 4. Papaioannou A, et al. Osteoporos Int 2008; 19(4):581-587. 5. Cranney A, et al. Osteoporos Int 2009; 20(9):1621-1625. 6. Cranney A, et al. CMAJ 2007; 177(6):575-580. 7. Langsetmo L, et al. J Bone Miner Res 2009; 24(9):1515-1522.

9. Back-up Material Additional slides that can be accessedby hyperlinks on core slides Section Two – Fragility Fractures and Care Gaps

10. Fracture is a Predictor of Future Fractures • The risk of experiencing another fracture in the year following a hip fracture*: 5% – 10%1,2 • The risk of experiencing another vertebral fracture in the year following a vertebral fracture†: 20%3 • Prevalent vertebral fractures also predict hip fracture*4,5 • 40% of Canadians who experience a fracture have a history of prior fracture6 1. Papaioannou A, et al. JOGC 2000; 22(8):591-597. 2. Colon-Emeric C, et al. Osteoporos Int 2003; 14:879-893. 3. Lindsay R, et al. JAMA 2001; 285:320-323. 4. Ismail AA, et al. Osteoporos Int 2001; 12(2):85-90. 5. Melton LJ 3rd, et al. Osteoporos Int 1999; 10(3):214-21. 6. Hajcsar EE, et al. CMAJ 2000, 163:819-822. * in men and women † in postmenopausal women Return to main presentation

11. One-year Mortality Risk after Hip Fracture 1 2 1. Ioannidis G, et al. CMAJ 2009; 181(5):265-271. 2. Papaioannou A, et al. J SOGC 2000; 22(8):591-597.

12. Increased Mortality Risk after Vertebral Fracture 1 2 Return to main presentation Ioannidis G, et al. CMAJ 2009; 181(5):265-271.

13. Multi (HUI2) Mobility(HUI2) Pain(HUI2) Self-care (HUI2) Multi(HUI3) Ambulation(HUI3) Pain(HUI3) 0 -0.05 -0.1 -0.15 -0.2 -0.25 Hip Spine Rib Other HUI3 Deficits Associated with Fracturesin Women, by Fracture Type Return to main presentation Papaioannou A, et al. Osteoporos Int 2009; 20(5):703-14.

14. Increasing Costs Associatedwith Hip Fracture ($CDN) Return to main presentation Wiktorowicz ME, et al. Osteoporos Int 2001; 12(4):271-278.

15. Therapeutic Care Gap: Most Men Do Not Receive Treatment for Osteoporosis after Fracture Return to main presentation Papaioannou A, et al. Osteoporos Int 2008; 19(4):581-587.

16. Post-fracture Care Gap:Comparison with Heart Attack 1. Bessette L, et al. Osteoporos Int 2008; 19:79-86. 2. Austin PC, et al. CMAJ 2008; 179(9):901-908. Return to main presentation

17. Most Fragility Fractures in Postmenopausal Women Occur with Low Bone Mass ("Osteopenia") 60 500 Fracture rate No. of fractures 50 400 40 300 There is a missed opportunity to prevent fractures due to over-reliance on BMD. Fracture rate, per 1000 person-years 30 No. of fractures 200 20 100 10 0 0 Normal Osteo-penia Osteo-porosis > 0.0 0.0to -0.5 -0.5to -1.0 -1.0to -1.5 -1.5to -2.0 -2.0to -2.5 -2.5to -3.0 -3.0to -3.5 ≤ -3.5 T-score WHO category Return to main presentation Cranney A, et al. CMAJ 2007; 177(6):575-580.