Projected number of osteoporotic hip fractures worldwideAdapted from Cooper C et al, Osteoporosis Int, 1992;2:285-289Estimated no of hip fractures: (1000s)742378Total number of hip fractures: 1950 = 1.66 million 2050 = 6.26 million

Health care providerHealth Care SystemPrivate versus public Doctors/ParamedicsPhysician/Surgeons/Nurses/RehabilitationPharmaceutical companiesCostSupportive programs

MediaPublicPatientsFamily and carers

A Still Neglected DiseaseIschemic heart diseaseDiabetes mellitusCerebro-vascular diseaseAIDS?????? OSTEOPOROSIS

Public health program does not include osteoporosisLow priorityNeglect the concept on skeletal health for all age groupsLack of driving force and support

Raising awareness about osteoporosis as a serious and debilitating diseaseIncreasing the priority of osteoporosis at national health policy planningUrgently considering osteoporosis on the list of chronic, disabling diseasesDefine essential care levels at a national levelDefine future strategies, projects and plan to fight osteoporosis

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

Programs onPreventionIdentification of high risk individualsEarly diagnosisEarly and appropriate treatment intervention Prevention of fallRehabilitation program for patients with fracture

Disease awarenessPriorityPro-activePhysician treating patients for other medical conditions are more proactive in identifying underlying osteoporosis High risk groupsTo assess fracture risks

DiagnosisTo initiate and suggest diagnostic measurement (DXA) to patientsCombined approach (Surgeon & Physician)Education Pharmacological interventionto offer appropriate treatment if indicatedto monitor treatment

Osteoporosis Self-assessment Tool for Asia (OSTA)Weight (kg)Age(yr)LOW RISKHIGH RISKmeasure BMD & treatAT RISKmeasure BMDHistory of prior non-violent fracture: consider BMD measurement and treatment

Assist decision makingAssist selection of appropriate treatmentAlgorithm

Operate and send home!

Post-operative careAmbulation and weight bearing

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

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.

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.

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 13:2052102. Kiebzak GM, Beinart GA, Perser K, Ambrose CG, Siff SJ, Heggeness MH 2002 Undertreatment of osteoporosis in men with hip fracture. Arch Intern Med 162:22172222

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** ***.*** 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 109:324326** Klotzbuecher CM, Ross PD, Landsman PB, Abbott III TA, Berger M 2000Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 15:721739* 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 57:599604

NO TREATMENT!!!!!!Patient Factors Osteoporosis?Default follow upPhysician/Surgeon FactorsAttitude Not interested, Who cares?, So What?AwarenessBusy practiceLack of physician-surgeon collaboration

Orthopedic surgeons treating low trauma fractures in postmenopausal women and older men need to take the next stepto 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.

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 familyto maintain physical activities to minimize fallto tailor rehabilitation program for individual patient to maximize their functional recovery

Public health problemSilent diseaseEarly diagnosis for high risk individualsThe need for long term therapyReduction of fracture risk

AcceptableUnderstand the need for long term treatmentAvailableDifferent classes of therapeutic agentsAccessibleBoth in urban and rural areasAffordableCost for long term treatment

Stimulators of bone formation(Fluoride)Parathyroid hormone

Mixed mechanism of actionVitamin D and metabolitesStrontium ranelate

For All PatientsCalcium and vitamin D

Inhibitors of bone resorption BisphosphonatesAlendronateRisedronateIbandronateZoledronateCalcitonin Estrogen progestin (SERMs)Raloxifene

DailyAlendronate 10mgStrontium ranelate 2gmRaloxifene 60mgWeeklyAlendronate 70mg, Alendronate Plus 70 mgRisedronate 35mgMonthlyIbandronate YearlyZoledronate

Just like hypertension, diabetes mellitus and other medical conditionsWhy monitor?Improve adherence and complianceTranslate into effective treatment outcomeReduction of fracture risks

Patients Show Poor Persistence Why Monitoring?NDC Health Study: Poor Persistence even with Weekly PrescriptionsEttinger M, et al. Arthritis Rheum. 2004;50(suppl):S513-S514. Abstract 1325.Data on file (Reference # 161-040), Hoffmann-La Roche Inc., Nutley, NJ 07110.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.

Monitoring Improves ComplianceThe Impact of Monitoring on Adherence and Persistence Source: Clowes et al (2004) The Journal of Clinical Endocrinology & Metabolism 89(3):1117-1123The 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.

Monitoring Techniques AcceptableAvailableAccessibleAffordableClinicalRadiologicalDXA scanBone turnover markers

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

Bone turnover markersAs early as three months after treatment with anti-resorptive agents

Bone turnover markersLimitationsNot readily available in Asian countriesMore important role in clinical practiceBaseline, three months and nine months after treatment

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

Promoting skeletal health in public throughout all age groupsPublic awareness on osteoporosisIdentification of at risk groupDiagnosisTreatment Patient support groupPatients with and without fracturesCarers

Patient and family should play the primary role in promoting treatment uptakeSupervise patients the correct way of taking their medicinesEnsure compliance and adherence Safe home environment

Health Care Providers

Doctors/ParamedicsPatients/Public

Thank You

*********************************Slide 34Speaker Notes:

Over the last few years, many new therapeutic options have become available for the prevention and treatment of osteoporosis. Commonly used agents include a variety of estrogen and estrogen-plus-progestin preparations, selective estrogen receptor modulators (SERMs) (such as raloxifene), calcitonin, and bisphosphonates (such as etidronate, alendronate, and risedronate). Calcium and vitamin D are recommended for all women at risk for osteoporosis unless there are specific contraindications.

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