Projected number of osteoporotic hip fractures worldwide Projected to reach million in Asia by 2050 Adapted from Cooper C et al, Osteoporosis Int, 1992;2: Estimated no of hip fractures: (1000s) Total number of hip fractures: 1950 = 1.66 million 2050 = 6.26 million

 Health care provider › Health Care System › Private versus public  Doctors/Paramedics › Physician/Surgeons/Nurses/Rehabilitation  Pharmaceutical companies › Cost › Supportive programs

 Media  Public  Patients › Family and carers

 A Still Neglected Disease › Ischemic heart disease › Diabetes mellitus › Cerebro-vascular disease › AIDS › ?????? OSTEOPOROSIS

 Public health program does not include osteoporosis  Low priority  Neglect the concept on skeletal health for all age groups  Lack of driving force and support

› Raising awareness about osteoporosis as a serious and debilitating disease › Increasing the priority of osteoporosis at national health policy planning › Urgently considering osteoporosis on the list of chronic, disabling diseases › Define essential care levels at a national level › Define future strategies, projects and plan to fight osteoporosis

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

 Programs on › Prevention › Identification of high risk individuals › Early diagnosis › Early and appropriate treatment intervention › Prevention of fall › Rehabilitation program for patients with fracture

 Disease awareness  Priority  Pro-active › Physician treating patients for other medical conditions are more proactive in identifying underlying osteoporosis  High risk groups › To assess fracture risks

 Diagnosis › To initiate and suggest diagnostic measurement (DXA) to patients  Combined approach (Surgeon & Physician) › Education  Pharmacological intervention › to offer appropriate treatment if indicated › to monitor treatment

Osteoporosis Self-assessment Tool for Asia (OSTA) Weight (kg) Age (yr) LOW RISK HIGH RISK measure BMD & treat AT RISK measure BMD History of prior non-violent fracture: consider BMD measurement and treatment

 Assist decision making  Assist selection of appropriate treatment  Algorithm

Operate and send home!

Post-operative care Post-operative care Ambulation 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 13:205– Kiebzak GM, Beinart GA, Perser K, Ambrose CG, Siff SJ, Heggeness MH 2002 Undertreatment of osteoporosis in men with hip fracture. Arch Intern Med 162:2217–2222

 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 109:324–326 ** Klotzbuecher CM, Ross PD, Landsman PB, Abbott III TA, Berger M 2000 Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 15:721–739 * 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 57:599–604

 NO TREATMENT!!!!!!  Patient Factors › Osteoporosis? › Default follow up  Physician/Surgeon Factors › Attitude – Not interested, Who cares?, So What? › Awareness › Busy practice › Lack of physician-surgeon collaboration

 Orthopedic surgeons treating low trauma fractures in postmenopausal women and older men need to take the next step  to 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 family to maintain physical activities to minimize fall  to tailor rehabilitation program for individual patient to maximize their functional recovery

 Public health problem  Silent disease  Early diagnosis for high risk individuals  The need for long term therapy  Reduction of fracture risk

 Acceptable › Understand the need for long term treatment  Available › Different classes of therapeutic agents  Accessible › Both in urban and rural areas  Affordable › Cost for long term treatment

Stimulators of bone formation  Fluoride)  (Fluoride)  Parathyroid hormone Mixed mechanism of action  Vitamin D and metabolites  Strontium ranelate For All Patients  Calcium and vitamin D Inhibitors of bone resorption Bisphosphonates –Alendronate –Risedronate –Ibandronate –Zoledronate Calcitonin Estrogen ± progestin (SERMs) (SERMs) –Raloxifene

 Daily › Alendronate 10mg › Strontium ranelate 2gm › Raloxifene 60mg  Weekly › Alendronate 70mg, Alendronate Plus 70 mg › Risedronate 35mg  Monthly › Ibandronate  Yearly › Zoledronate

 Just like hypertension, diabetes mellitus and other medical conditions  Why monitor?  Improve adherence and compliance  Translate into effective treatment outcome  Reduction of fracture risks

Patients Show Poor Persistence Why Monitoring? NDC Health Study: Poor Persistence even with Weekly Prescriptions Ettinger M, et al. Arthritis Rheum. 2004;50(suppl):S513-S514. Abstract Data on file (Reference # ), Hoffmann-La Roche Inc., Nutley, NJ 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 Compliance The Impact of Monitoring on Adherence and Persistence Source: Clowes et al (2004) The Journal of Clinical Endocrinology & Metabolism 89(3): The 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 › Acceptable › Available › Accessible › Affordable  Clinical  Radiological  DXA scan  Bone turnover markers

 DXA › BMD changes with pharmacological agents only explain partially the reduction of fracture risk › Significant changes seen only after 1 ½ to 2 years of treatment

 Bone turnover markers › As early as three months after treatment with anti-resorptive agents

 Bone turnover markers › Limitations › Not readily available in Asian countries › More important role in clinical practice › Baseline, 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 groups  Public awareness on osteoporosis  Identification of at risk group › Diagnosis › Treatment  Patient support group › Patients with and without fractures › Carers

 Patient and family should play the primary role in promoting treatment uptake  Supervise patients the correct way of taking their medicines  Ensure compliance and adherence  Safe home environment

Health Care Providers Doctors/Paramedics Patients/Public

Thank You