PITNAS PEROSI

Surabaya 26-27 Oktober 2018

Algorithm of
OSTEOPOROSIS
NICOLAAS C. BUDHIPARAMA, MD

NICOLAAS FOUNDATION OF CONSTRUCTIVE ORTHOPAEDIC RESEARCH & EDUCATION

FOUNDATION FOR ARTHROPLASTY & SPORTS MEDICINE

Presented by dr.B.P.Putra Suryana SpPD-KR

Rheumatology Division – Internal Medicine, Brawijaya University – Saiful Anwar Hospital,
Malang
OSTEOPOROSIS IS A SERIOUS PUBLIC
HEALTH PROBLEM

70%
of people over 65 with osteoporosis
have never been screened and don’t
know they have osteoporosis
 OSTEOPOROSIS IN INDONESIA
Burden in Indonesia :
• Population 220 mill
• > 50 yrs - Male 16 mill; Woman 17 mill
• Year 2020 population 261 mill
• Year 2050 population 273 mill
• Study 2005 : Kompas 5 Nov : 3.6 mill OP patients
• Prevalence Osteoporosis 10.3%
• Prevalence Osteopenia 41.8%
What are challenges?
 UNDERDIAGNOSED & UNDERTREATED

• Underdiagnosed: National Osteoporosis Risk Assessment (NORA)

study (200,160 postmenopausal women)1
– 40% osteopenic
– 7% osteoporotic
– 11% ≥1 fracture after age 45 years

• Undertreated: women meeting criteria for treatment2

– 15.7% not taking calcium
– 18.6% not taking vitamin D
– 52.7% not exercising >2 hrs per week
– 35.3% not receiving therapy
1. Siris ES, et al. JAMA. 2001;286:2815-2822.
2. Schnatz PF, et al. Menopause. 2011;18:1072-1078.
 THE CLINICAL CHALLENGE

• Often asymptomatic1
–Until fracture occurs1
–Even after some fractures (eg, 2/3 of
vertebral fractures are asymptomatic)2
• The challenge to clinicians1:
–Identify patients at high risk for fracture
–Prevent first fracture

1. South-Paul JE. Am Fam Physician. 2001;63:1121-1128.

2. Lenchnik L, et al. AJR. 2004;183:949-958.
 FRACTURE FACTS
• 2 million bone breaks a year (“2 million 2 many”)1
• Only 2 in 10 patients with osteoporosis get a follow-up test or
treatment for osteoporosis1
• Fractures may have serious consequences2
–Hip fracture
• 10%-20% additional mortality per year
• 20% of hip fracture patients require long-term nursing home
care
• Only 40% fully regain their pre-fracture level of independence1
1. National Bone Health Alliance. 2 Million 2 Many. Available at: http://www.2million2many.org/. Accessed September 13,
2013. 2. US Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General.
Rockville, MD: US Department of Health and Human Services, Office of the Surgeon General; 2004. Available at:
http://www.surgeongeneral.gov/library/reports/bonehealth/full_report.pdf. Accessed September 13, 2013.
 WHERE ARE WE NOW ?
THE GOOD NEWS THE BAD NEWS
Under-recognition of patients at risk
Improved awareness
for fracture
Decreasing access to DXA
Excellent diagnostic tools available
Poor patient understanding of
FRAX is a quantitative risk risk/benefit
assessment Increasing patient concerns about side
effects
Safe and effective individualized
treatment Fewer patients on therapy

Better understanding of Poor adherence

pathogenesis • 30% of patients don’t pick up new
bisphosphonate prescriptions
Federal initiatives to improve care • Risk of fracture increased 30–40%
Algorithm in
diagnosis?
 RISK FACTOR ASSESSMENT

Risk for osteoporosis /

BMD testing Risk for fall
• Age • Age
• Female • Female
• Low body mass index • Anxiety, depression
• Glucocorticoid • Arrhytmias
• Rheumatoid arthritis • Dehydration
• Family history • Malnutrition
• Smoking • Medication
• Alcohol intake • Poor vision
• Orthostatic hypotension
• Environment

National Osteoporosis Foundation,2008

BMD TEST USING DXA
METHOD IS STANDARDIZED TEST
FOR OSTEOPOROSIS
ALGORITHM FOR OSTEOPOROSIS
DIAGNOSIS & MANAGEMENT
 ALGORITHM FOR OSTEOPOROSIS DIAGNOSIS

Women ≥ 65 and men ≥ 70

(younger with risk factors)

DXA test

T-score ≤ -2.5 in the lumbar spine, T-score between -1.0 and -2.5
total hip, or femoral neck
or
Hip or spine fracture (clinical or radiographic) FRAX
10-y fracture risk
YE
S
≥ 3% for hip fracture
Candidate for YES or
TREATMENT ≥ 20% for major osteoporotic fractures
 FRAX
• Statistically robust fracture risk prediction tool developed
by the WHO for world-wide use
• Combines BMD + clinical risk factors to predict fracture
risk better than either alone
• Predicts the 10-year probability of major osteoporotic
fracture
– Hip, spine, wrist, or humerus
• Use when the decision to treat is uncertain
WHO FRAX® Tool. http://www.shef.ac.uk/FRAX/. Accessed September 13, 2013.
Fracture risk calculation : FRAX
 FRAX
Benefits
Derives 10-year probability of
clinical event from measurable
parameters
Internationally recognized and
validated
Based on data from multiple
cohorts
Easily accessible on the
Internet or DXA software
Helps identify patients who
need treatment
Can be used to reassure low-
risk patients
Limitations
Not valid to monitor patients on
treatment
Only femoral neck BMD is considered
Risk is “yes/no” – there is no
consideration of “dose”
(e.g., fractures, glucocorticoids,
smoking, alcohol)
Not all risk factors are included (eg,
risk of falling)
Clinical judgment is required
Do patients with high FRAX scores
benefit from medication? (Unknown)
 The role of FRAX for treatment

Ten year probability of fracture

Major osteoporotic fracture > 20%
Hip fracture > 3%
Algorithm for the
use of bone
markers in
treatment
decision
Srivastava AK et al, Curr Med
Res Opin 2005;21(7)
Algorithm in
treatment?
 2016 UNIVERSAL RECOMMENDATIONS

Counsel on the risk of fractures

Eat a diet rich in fruits and vegetables (supplemented if necessary)
to a total calcium intake of
• 1000 mg per day for men 50-70
• 1200 mg per day for women ≥ 51
• 1200 mg per day for men ≥ 71
Vitamin D intake should be 800-1000 IU per day (age ≥50),
supplemented if necessary
Regular weight-bearing and muscle-strengthening exercise
Fall prevention evaluation and training

Cessation of tobacco use and avoidance of excessive alcohol intake

 EXERCISE

Weight-bearing exercises stimulate osteocytes and decrease risk of fall.

 FALL PREVENTION

Good home environment prevents fall

CALCIUM AND VIT D FOOD
SOURCES
SUN EXPOSURES
 TREATMENT FOR OSTEOPOROSIS
BIPHOSPHONATES

• First line treatment for primary and secondary prevention

of osteoporotic fractures
• Reduce bone resorption by inhibiting action of osteoclasts

• Available orally as daily or weekly tablet, or as a yearly

injection
• Daily and weekly- alendronate, risedronate
• Yearly IV- zoledronate infusion
 ATYPICAL FRACTURES IN PATIENTS TAKING
ANTI-RESORPTIVE AGENTS LONG TERM

• May begin with stress reaction or stress

fracture of lateral femoral cortex (A)
• Transverse fractures of femoral
diaphysis or in subtrochanteric region (B)
• Often bilateral
• Prodromal pain in thigh or groin in 70%
• Occurs in untreated patients, but
increased incidence with long-term
antiresorptive therapy, particularly
bisphosphonates and denosumab

Park-Wyllie LY, et al. JAMA. 2011;305:783-789. Shane E, et al. J Bone Miner Res. 2013 May 28. [Epub ahead of print].
Watts NB, Diab DL. J Clin Endocrinol Metab. 2010;95:1555-1565. Meier RP. Arch Intern Med. 2012;172:930-936.
 BIPHOSPHONATES HOLIDAYS

• In patients at high risk for fractures, continued treatment

seems reasonable. Consider a drug holiday of 1 to 2 years after
10 years of treatment
• For lower risk patients, consider a “drug holiday” after 4 to 5
years of stability
• Follow BMD and bone turnover markers during a drug holiday
period, and reinitiate therapy if bone density declines or
markers increase

Watts NB et al; AACE Osteoporosis Task Force. Endocr Pract. 2010;16(Suppl 3):1-37.
Whitaker M, et al. N Engl J Med. 2012;366(22):2048-2051.
 TREATMENT SUMMARY
Anti-resorptive agents
• Prevent bone loss and preserve architecture
• Improve quality of bone
• Reduce the risk of vertebral fractures (all agents)
• Alendronate, risedronate, zoledronic acid, and denosumab
proved to reduce the risk of nonvertebral and hip fractures
Anabolic agent
• Increases bone density and size
• Improves quality of bone
• Reduces the risk of vertebral and nonvertebral fractures; no hip
fracture data
Patient factors determine the most appropriate drug to use
 MOST PATIENTS DISCONTINUE ORAL
BIPHOSPHONATES SOON AFTER
TREATMENT INITIATIONS
100 Rapid drop in persistence
due to nonacceptance
Percent Adherent on Weekly

80
Bisphosphonate

Further decrease in persistence due to multiplicity of factors

60

40

20

0
0 3 6 9 12
Months Following Therapy Initiation

With permission from Springer Science+Business Media: Weycker D, et al. Compliance with drug therapy for
postmenopausal osteoporosis, Osteoporos Int, 2006;17:1645-1652. Figure 1. © International Osteoporosis
Foundation and National Osteoporosis Foundation 2006.
 SIDE EFFECTS & ADHERENCE

• Discuss side effects of the medicines

• Put into perspective of risk vs benefits
• Reiterate patient's high risk of fracture
• Address other information sources
(media, Internet, friends)
–May deter from starting
–Encourage to stop use
 MONITORING IS IMPORTANT
• Monitor treatment with DXA every 1–2 years
– Do not "over-interpret" change
– Be happy when BMD is stable OR increasing

• Why do some patients lose BMD on treatment?

– Adherence
– Drug pharmacokinetics
– Underlying disorders that need to be addressed

• Patients on treatment whose BMD remains low are at high risk of

fracture and may benefit from longer treatment
 SECONDARY FRACTURE PREVENTION

• A fracture is a sentinel event

• A fracture in a person over 50 is the most powerful risk factor for
a future fracture
• Many high risk patients have their fractures successfully treated
but do NOT receive assessment and treatment to prevent the next
fracture
• Fracture Liaison Service (FLS) is an emerging model for secondary
prevention
 SUMMARY
Algorithm in diagnosis and treatment
of osteoporosis provide guidance for
better management of osteoporosis
including early detection and
prevention, fracture prevention, and
increase patient compliance.