Transcript Osteoporosis: Measuring the Problem Dr. Tuan V. Nguyen Associate Professor Bone and Mineral Research Program Garvan Institute of Medical Research Sydney, Australia.

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?
Increase in life expectancy
75
80
70
55
Years
60
50
43
40
30
33
22
20
10
0
Roman
Empire
Middle Age
Mid-19th
century
Early 1900
Now
WHO. Human Population: Fundamentals of Growth World Health, 2000.
The ageing of population
Percent of population aged 65+
25
World
Australia
20
Percent
15
10
5
0
1996
2001
2011
2021
2031
2041
ABS and US Bureau of Census, 1996.
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)
Shift in thinking
RISK FACTOR
OUTCOME
Osteoporosis
Bone
Strength
Fracture
Bone
Quality
and
Bone
Mineral
Density
Architecture
Turnover rate
Damage accumulation
Degree of mineralization
Properties of the collagen/mineral matrix
<0
.4
0
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
-
Prevalence
18
T < 2.5
osteoporosis
16
0.8
14
0.7
12
0.6
10
0.5
8
0.4
6
0.3
4
0.2
2
0.1
0
0
Femoral neck BMD
10-year Risk of Fx
BMD and fracture
0.9
14-year risk of fractures in WOMEN aged 60+
1287women
Osteoporosis
345 (27%)
Fx = 137
(40%)
No Fx =
208 (60%)
42%
Non-osteoporosis
942 (73%)
Fx = 191
(20%)
No Fx = 751
(80%)
14-year risk of fractures in MEN aged 60+
821 men
Osteoporosis
N = 90 (11%)
Fx = 27
(30%)
No Fx = 63
(70%)
23%
Non-osteoporosis
731 (89%)
Fx = 91
(12%)
No Fx = 640
(88%)
Magnitude of the Problem
Incidence of all-limb fractures
Rate per 100,000 population
500
400
300
200
100
0
0-4
5-14
15-24 25-34 35-44 45-54 55-64 65-74 75-84
Age group
85+
Annual fracture incidence in Australia 1996-2051
250
207.66
200
1000
150.74
150
100
93.75
104.42
115.27
125.86
50
0
2001
2006
2011
2016
2026
2051
Projected annual number of all-limb fractures in Australia aged
35+ (Sanders et al, MJA 1999)
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)
Lifetime risk of some diseases women
Any osteoporotic fracture
1/2
Hip fracture
1/6
Clinical vertebral fracture
1/4
Cancer (any site)*
2/5
Breast cancer*
Lung/bronchus*
1/8
1/16
Coronary heart diseases
1/4
Diabetes Mellitus
0
*, from birth
1/3
10
20
30
40
50
Residual lifetime risk (%)
(from the age of 50)
60
70
Lifetime risk of some diseases - men
1/3
Any osteoporotic fracture
Hip fracture
1/16
Clinical vertebral fracture
1/8
Cancer (any site)*
3/7
Prostate cancer*
Lung/bronchus*
1/8
1/16
Coronary heart diseases
1/3
Diabetes Mellitus
0
*, from birth
1/2
10
20
30
40
Residual lifetime risk (%)
(from the age of 50)
50
60
Ten-year and lifetime risk of fractures
10-y risk
60
Lifetime risk
Women
Men
60
50
50
40
40
(%)30
(%) 30
20
20
10
10
0
60
65 70 75
80
85
0
60
65
70
75
80
Age free of fracture (y)
Age free of fracture (y)
 with advancing age
 with advancing age
85
10-y risk
Lifetime risk
Ten-year and lifetime risk of fractures
70
60
50
(%) 40
30
20
10
0
(%)
Normal
Osteopenia
Osteoporosis
T-scores >-1.0
-2.5 < T-scores < -1.0
T-scores < -2.5
Women
Men
60
65
70
75
80
85
70
60
50
40
30
20
10
0
60
65
70
75
80
85
70
60
50
40
30
20
10
0
70
70
60
Age free-of-fracture (y)70
60
60
50
50
50
40
40
40
30
30
30
20
20
20
10
10
10
0
60
65
70
75
80
85
0
60
65
70
75
80
85
Age free-of-fracture (y)
0
60
65
70
75
80
60
65
70
75
80
85
85
Ten-year and lifetime risk of any fracture by BMD and age
FNBMD
(T-score)
10-year risk
Lifetime risk
Age free of fracture (y)
Age free of fracture (y)
60
70
80
60
70
80
WOMEN
> -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
Osteoporotic Fractures
Survival probability in those
with and without fracture
A
Women
B
1.0
1.0
0.9
0.9
0.8
Non-fracture
0.7
0.6
0.5
0.4
0.3
Any fracture
0.2
0.1
Cummulative survival proportion
Cummulative survival proportion
Men
0.8
0.7
Non-fracture
0.6
0.5
0.4
0.3
0.2
0.1
0.0
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15
Time to follow-up (year)
Any fracture
0.0
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15
Time to follow-up (year)
Nguyen et al, 2005
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
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
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
Asymptomatic vertebral fracture
increases risk of subsequent
fractures
300 m+w
66 V #
29 Fx
44%
234 No V #
37 no fx
54 Fx
180 no fx
23%
Pongchaiyakul C et al, J Bone Miner Res 2005
Asymptomatic vertebral fracture
increases risk of death
300 m+w
66 V #
20 deaths
30%
234 No V #
46 survived
25 deaths
209 survived
11%
Pongchaiyakul C et al, J Bone Miner Res 2005
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
Utility loss associated with fracture
0.50
First year
Subsequent year
0.40
0.30
0.20
0.10
0.00
Hip
Tibia
and
fibula
Vertebra
Ribs
Pelvis
Humerus Clavicle, Distal
sternum forearm
Under-treated & Under-diagnosis
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)
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)
Levels of treatment in fractured
women in primary care settings
N = 20,248
27.9
30.00
20.00
12.5
15.00
12.3
8.5
10.00
8.3
7.2
5.00
2.2
x
+
ot
he
rR
on
ly
al
ciu
m
al
ciu
m
C
R
al
ox
ife
ne
al
cit
rio
l
C
Eisman JA, et al, J Bone Miner Res 2004
C
os
ph
on
at
es
T
R
Bi
sp
h
H
R
x
0.00
An
y
Percent
25.00
Level of treatment in outpatients
157 lowtrauma fx
Prior fx:
76
No prior fx:
81
BMD:
Any Rx:
BMD:
Any Rx:
35 (45%)
14 (18%)
18 (22%)
3 (10%)
Bliuc D, et al, Osteoporosis Int 2004
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
Risk factor modifications for fracture
Intervention
Bisphosphonates, HRT, SERMs
Estimated
change in fx
risk
~30-50%
Quit smoking
-38%
Treat impaired vision
-50%
Stop sedatives
-40%
Hip protectors
-50%?
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
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 underdiagnosed.