Upload
darlene-dickerson
View
215
Download
0
Embed Size (px)
Citation preview
Osteoporosis: Osteoporosis: Measuring the ProblemMeasuring the Problem
Dr. Tuan V. NguyenDr. Tuan V. NguyenAssociate ProfessorAssociate Professor
Bone and Mineral Research ProgramBone and Mineral Research ProgramGarvan Institute of Medical ResearchGarvan Institute of Medical Research
Sydney, AustraliaSydney, Australia
Measuring osteoporotic Measuring osteoporotic fracturesfractures
• Magnitude of the problem
• Consequences
• Undertreated, underdiagnosed and what to do?
Increase in life expectancyIncrease in life expectancy
22
33
43
55
75
0
10
20
30
40
50
60
70
80
RomanEmpire
Middle Age Mid-19thcentury
Early 1900 Now
Yea
rs
WHO. Human Population: Fundamentals of Growth World Health, 2000.
The ageing of populationThe ageing of population
0
5
10
15
20
25
1996 2001 2011 2021 2031 2041
Per
cent
World Australia
Percent of population aged 65+
ABS and US Bureau of Census, 1996.
Osteoporosis – shift in Osteoporosis – shift in definitionsdefinitions
“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)
Shift in thinkingShift in thinking
BoneQuality
BoneStrength and
ArchitectureTurnover rateDamage accumulationDegree of mineralizationProperties of the collagen/mineral matrix
BoneMineralDensity
Osteoporosis FractureRISK FACTOR OUTCOME
BMD and fractureBMD and fracture
0
2
4
6
8
10
12
14
16
18
<0.40
0.40-
0.45-
0.50-
0.55-
0.60-
0.65-
0.70-
0.75-
0.80-
0.85-
0.90-
0.95-
1.00-
1.05-
1.10-
Femoral neck BMD
Pre
vale
nce
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
10-y
ear
Ris
k o
f F
x
T < 2.5 osteopor
osis
14-year risk of fractures in 14-year risk of fractures in WOMEN aged 60+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%)
42%
14-year risk of fractures in MEN 14-year risk of fractures in MEN aged 60+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%)
23%
Magnitude of the Magnitude of the ProblemProblem
Incidence of all-limb Incidence of all-limb fracturesfractures
0
100
200
300
400
500
0-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+
Age group
Rate
per
100,0
00 p
op
ula
tio
n
Annual fracture incidence in Annual fracture incidence in Australia Australia 1996-20511996-2051
93.75104.42
115.27125.86
150.74
207.66
0
50
100
150
200
250
2001 2006 2011 2016 2026 2051
1000
Projected annual number of all-limb fractures in Australia aged 35+ (Sanders et al, MJA 1999)
Hip, vertebrae, and Colles Hip, vertebrae, and Colles fracturesfractures
FractureFracture 20062006 20512051
HipHip 20,70020,700 60,00060,000
VertebraeVertebrae 14,50014,500 31,70031,700
CollesColles 11,90011,900 23,00023,000
HumerusHumerus 7,5007,500 16,30016,300
PelvisPelvis 4,1004,100 9,8009,800
Projected annual number of all-limb fractures in Australia aged 35+(Sanders et al, MJA 1999)
Lifetime risk of some Lifetime risk of some diseases - womendiseases - women
Any osteoporotic fracture
Hip fracture
Clinical vertebral fracture
Cancer (any site)*
Breast cancer*
Lung/bronchus*
Coronary heart diseases
Diabetes Mellitus
*, from birth Residual lifetime risk (%)
0 10 20 30 40 50 60 70
1/2
1/6
1/4
2/5
1/8
1/16
1/4
1/3
(from the age of 50)
Lifetime risk of some Lifetime risk of some diseases - mendiseases - 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)
Residual lifetime risk (%)
0 10 20 30 40 50 60
1/3
1/16
1/8
3/7
1/8
1/16
1/3
1/2
Ten-year and lifetimeTen-year and lifetime risk of risk of fracturesfractures
Age free of fracture (y)
(%)
0
10
20
30
40
50
60
60 65 70 75 80 85Age free of fracture (y)
(%)
0
10
20
30
40
50
60
60 65 70 75 80 85
WomenMen
with advancing age with advancing age
10-y risk Lifetime risk
Ten-year and lifetimeTen-year and lifetime risk of risk of fracturesfractures
Osteoporosis T-scores < -2.5
Osteopenia -2.5 < T-scores < -
1.0
NormalT-scores >-1.0
Lif
etim
e ri
sk
Age free-of-fracture (y)
10-
y r
isk
Age free-of-fracture (y)
(%)
0
10
20
30
40
50
60
70
60 65 70 75 80 85
WomenMen
0
10
20
30
40
50
60
70
60 65 70 75 80 850
10
20
30
40
50
60
70
60 65 70 75 80 85
(%)
0
10
20
30
40
50
60
70
60 65 70 75 80 850
10
20
30
40
50
60
70
60 65 70 75 80 850
10
20
30
40
50
60
70
60 65 70 75 80 85
Ten-year and lifetimeTen-year and lifetime risk of any fracture by risk of any fracture by BMD and ageBMD and age
FNBMDFNBMD 10-year risk10-year risk LifetimeLifetime risk risk
(T-score)(T-score) Age free of fracture (y)Age free of fracture (y) Age free of fracture (y)Age free of fracture (y)
6060 7070 8080 6060 7070 8080
WOMENWOMEN
> -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
> -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
Consequences of Consequences of Osteoporotic FracturesOsteoporotic Fractures
Survival probability in thoseSurvival probability in thosewith and without fracturewith and without fracture
Time to follow-up (year)
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Cu
mm
ula
tive
su
rviv
al p
rop
ort
ion
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Non-fracture
Any fracture
B Men
Time to follow-up (year)
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Cu
mm
ula
tive
su
rviv
al p
rop
ort
ion
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Non-fracture
Any fracture
A Women
Nguyen et al, 2005
Risk of death from hip Risk of death from hip fracturefracture
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
Impact of hip fracturesImpact of hip fractures
25% die within 6 months (*)25% die within 6 months (*) 60% have restricted mobility (*)60% have restricted mobility (*) 25% remain functionally more 25% remain functionally more
dependentdependent Cardiac (8%) and pumonary Cardiac (8%) and pumonary
complication (4%)complication (4%) Transient heart attacksTransient heart attacks Non-union and avancular necrosisNon-union and avancular necrosis
(*) Data from the Dubbo Osteoporosis Epidemiology Study
Impact of vertebral Impact of vertebral fracturesfractures
Symptomatic fx : Lifetime risk 1/4 Symptomatic fx : Lifetime risk 1/4 women, 1/8 men women, 1/8 men
Asymptomatic fx prevalence: 20-30%Asymptomatic fx prevalence: 20-30%
Back pain, functional limitationBack pain, functional limitation Rib-against-pelvis (RAP) syndromeRib-against-pelvis (RAP) syndrome Costoiliac impingement syndromeCostoiliac impingement syndrome Decrease vital lung capacityDecrease vital lung capacity
Pongchaiyakul C et al, J Bone Miner Res 2005
Asymptomatic vertebral Asymptomatic vertebral fracture increases risk of fracture increases risk of
subsequent fracturessubsequent fractures300 m+w
234 No V #66 V #
29 Fx 37 no fx 54 Fx 180 no fx
44% 23%
Pongchaiyakul C et al, J Bone Miner Res 2005
Asymptomatic vertebral Asymptomatic vertebral fracture increases risk of fracture increases risk of
deathdeath300 m+w
234 No V #66 V #
20 deaths 46 survived 25 deaths 209 survived
30% 11%
Pongchaiyakul C et al, J Bone Miner Res 2005
Impact of wrist fractureImpact of wrist fracture
More common in women in their More common in women in their 50s50s
Post-traumatic arthritisPost-traumatic arthritis Account for 39% of all physical Account for 39% of all physical
therapy sessionstherapy sessions Reduced daily living activiesReduced daily living activies
Melton LJ, J Bone Miner Res 2003
Utility loss associated with Utility loss associated with fracturefracture
0.00
0.10
0.20
0.30
0.40
0.50
Hip Tibiaand
fibula
Vertebra Ribs Pelvis Humerus Clavicle,sternum
Distalforearm
First year
Subsequent year
Under-treated & Under-Under-treated & Under-diagnosisdiagnosis
What the experts say? What the experts say? ““All women and men with a history of All women and men with a history of
fragility fractures should be considered fragility fractures should be considered for treatment of osteoporosis to reduce for treatment of osteoporosis to reduce their risk of future fracturetheir risk of future fracture.” (.” (Seeman Seeman and Eisman, MJA 2004and Eisman, MJA 2004))
““Initiate therapy to reduce fracture Initiate therapy to reduce fracture risk in postmenopausal women with risk in postmenopausal women with BMD T-scores by DXA below -2 in the BMD T-scores by DXA below -2 in the absence of risk factors and in women absence of risk factors and in women with T-scores below -1.5 if one or more with T-scores below -1.5 if one or more risk factors are presentrisk factors are present.” (.” (NOF 2003NOF 2003))
What the experts say? What the experts say?
““Recommend BMD testing to Recommend BMD testing to postmenopausal women who have postmenopausal women who have suffered a fragility fracture to confirm suffered a fragility fracture to confirm the diagnosis and determine disease the diagnosis and determine disease severityseverity.” (.” (NOF 2003NOF 2003))
Levels of treatment in Levels of treatment in fractured women in primary fractured women in primary
care settingscare settings
27.9
12.5
8.5 8.3
2.2
7.2
12.3
0.00
5.00
10.00
15.00
20.00
25.00
30.00
Any R
xHRT
Bispho
spho
nate
s
Calcitr
iol
Raloxif
ene
Calcium
only
Calcium
+ o
ther
Rx
Per
cen
t
Eisman JA, et al, J Bone Miner Res 2004
N = 20,248
Level of treatment in Level of treatment in outpatientsoutpatients
157 low-trauma fx
No prior fx: 81
Prior fx: 76
BMD:
35 (45%)
Any Rx:
14 (18%)
BMD:
18 (22%)
Any Rx:
3 (10%)
Bliuc D, et al, Osteoporosis Int 2004
Level of treatment – Level of treatment – experience in the USexperience in the US
502 hospitalised hip-fracture patients:502 hospitalised hip-fracture patients: only 14% had BMD scansonly 14% had BMD scans 13% received calcium and/or vitamin D13% received calcium and/or vitamin D 18% received HRT, calcitonin, or 18% received HRT, calcitonin, or
bisphosphonates.bisphosphonates.
Harrington JT, et al. Arthritis Rheum 2002; 47: 651-654
Risk factor modifications Risk factor modifications for fracturefor fracture
InterventionIntervention Estimated Estimated change in change in
fx riskfx risk
Bisphosphonates, HRT, Bisphosphonates, HRT, SERMsSERMs
~30-50%~30-50%
Quit smokingQuit smoking -38%-38%
Treat impaired visionTreat impaired vision -50%-50%
Stop sedativesStop sedatives -40%-40%
Hip protectorsHip protectors -50%?-50%?
SummarySummary
In individuals aged 60+: 25% women and In individuals aged 60+: 25% women and 11% men a11% men are osteoporosis (eg low BMD)re osteoporosis (eg low BMD)
Lifetime risk of fracture (from the age of Lifetime risk of fracture (from the age of 50): 1/3 men and 1/2 women.50): 1/3 men and 1/2 women.
With the presence of osteoporosis, With the presence of osteoporosis, lifetime risk increase to 1/2 men and lifetime risk increase to 1/2 men and 7/10 women7/10 women
SummarySummary
Fracture, particularly hip fracture, is a Fracture, particularly hip fracture, is a serious public health problem in the serious public health problem in the elderly.elderly.
Increase mortality risk, reduced quality Increase mortality risk, reduced quality of life, incurred health care costsof life, incurred health care costs
Osteoporosis is both under-treated and Osteoporosis is both under-treated and under-diagnosed.under-diagnosed.