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Osteoporosis in Malaysia
Dr LEE Joon Kiong President, Osteoporosis Awareness Society of Kuala Lumpur
Secretary & Past President, Malaysian Osteoporosis Society
Malaysia
Malaysia’s total population of 28 million in 2010, those above 65 years of age is estimated to be 4.7%
Malaysian men are expected to live up to 71 years of age while women will live up to 77.1 years. The longer life span is attributed to the improvements in accessibility to health and medical services
There is no data on the incidence of patients with osteopenia, osteoporosis as well as incidence of osteoporosis related vertebral fractures.
Malaysia The overall incidence of hip fractures was 90 per 100 000
individuals. Overall, 63% of patients presenting with hip fractures were Chinese, 20% were Malays and Indians 13%
Race and sex-specific incidence data showed that the incidence was highest among Chinese females (220 per 100 000), followed by Indian females (200 per 100 000)
The age-specific incidence was 500 per 100 000 for patients above 75 years, compared to 10 per 100 000 in those between 50 and 54 years
Malaysia
There is still a lack of awareness among health care providers. The public health program does not include osteoporosis as one of the high priority conditions.
There is also lack of driving force and support from Ministry of Health to promote bone health.
Still A Neglected Disease
Health Care System in Asia
Osteoporosis is not yet
recognized as a major
health problem by the
government
No government public
awareness programs
covering prevention,
diagnosis and
management of
osteoporosis
Clinical Practice Guideline
Malaysian
Osteoporosis Society
Risk Factors for Osteoporosis and Fracture
Non-Modifiable Modifiable Advancing age
Ethnic group (Oriental & Caucasian)
Female gender
Premature menopause (< 45 years) including surgical menopause
Family history of osteoporosis or fracture in first degree relative
Personal history of fracture as an adult
Low calcium and/or vitamin D intake
Sedentary lifestyle
Cigarette smoking
Excessive alcohol intake (>3 units/day)
Excessive caffeine intake (>3 drinks/day)
Low body weight (BMI < 19 kg/m2)
Estrogen deficiency
Impaired vision
Recurrent falls
Number of DXA machines per 10,000 population
The generally recommended number of DXA per 10 000 population is 0.11 in Europe. It is clear that most of the countries in this audit fall well below this recommendation
IOF 3rd Asia-Pacific Regional Meeting Kuala Lumpur (JK Lee)
FRAX
Uploaded FRAX data
among Asian countries
Which FRAX if NO FRAX ?
Interpretation and Use of FRAX® in Clinical Practice
15
Consensus of ISCD/IOF FRAX Initiatives in Asia-Pacific Region
Australia - Richard Prince
China Mainland - Yan-Ling Zhao, Wei Yu
Indonesia - Gunawan Tirtarahardja
Japan - Akira Itabashi
Korea - Soo-Shin Chan
Malaysia - Joon-Kiong Lee
Philippine - Julie Li-Yu
Singapore - Siok-Bee Chionh
Taiwan - Paulo Wu, Derrick Chan, Keh-Sung Tsai, Chieng Poon Ung, Rong-Sen Yang, Sheng-Pin Changlai
UK (IOF) - Eugene McCloskey
USA (ISCD) - Bobo Tanner
Consensus of ISCD/IOF FRAX Initiatives in Asia-Pacific Region Expert Panel
Kanis, Osteoporos Int 2012;15 Mar
Hip Fractures in Women
>300 per 100,000
200-300 per 100,000
<200 per 100,000
0
200
400
600
Age
-sta
nda
rdiz
ed a
nn
ua
l in
cid
en
ce
(ra
te/1
00
,00
0)
Classification of Countries within Asia-Pacific Regions According to the Population Risk of Hip Fracture
Category of
Risk* Similar Regions
Very High Taiwan
High Hong Kong Singapore
Medium Australia Japan Korea, Republic
Malaysia
New Zealand Thailand
Low China Mainland India Indonesia Pakistan
Philippines Sri Lanka Vietnam
Undetermined Bangladesh Bhutan Brunei Cambodia
Laos Korea, DPR Myanmar New Caledonia
Papua New
Guinea
* The category of risk is summarized from the documented data of women aged 50 and above.
USA Asians FRAX
2.4%
0.4%
Singapore
Malay
FRAX
Hong Kong FRAX
Clinical Practice
Guideline (2012)
FRAX
The country-specific FRAX prediction algorithms are available for some countries but not for Malaysia. For Malaysians, we recommend the use of ethnic specific algorithms (e.g. Singapore Chinese, Singapore Malay, Singapore Indian or Hong Kong) until local data is available.
Clinical Practice Guideline (2012) - FRAX
In patients with osteopenia, initiation of treatment is recommended with a fracture probability of more than 3% at 10 years for hip or 20% at 10 years for major osteoporosis related fracture.
If FRAX is not accessible, elderly individuals over 65 years of age with multiple risk factors who are at sufficiently high risk for osteoporosis, can be started on treatment.
Clinical Practice Guideline (2012) - FRAX
Post Menopausal Osteoporosis
Male Osteoporosis
GIOP
Who to treat?
Clinical risk factors?
Presence of low trauma factures?
DXA?
Osteopenia?
Osteoporosis?
Treatments for Osteoporosis Anti-resorptives
Estrogen ± progesterone (Daily)
SERM
Raloxifene (Daily)
Bisphosphonates
Alendronate Plus (Weekly)
Ibandronate (Monthly)
Risedronate (Weekly)
Zoledronate (Yearly)
Biologics
Denosumab (6 monthly)
Anabolic r-PTH (Daily)
Basic Calcium and vitamin D
(Daily)
Other Strontium ranelate
(Daily)
Treatments Available
Clinical Guidance on the Management of Osteoporosis 2012
Monitoring
Monitoring
Aim: To assess the response to treatment
Clinical Guidance for Mx Osteoporosis 2012 - Chapter 4
1) DXA 2) Bone Turnover markers
Monitoring of treatment
Patients should have regular clinical assessments
DXA (spine/hip) – performed at 1-2 year intervals, preferably with the same machine Monitoring with QUS / peripheral DXA is not
recommended
Monitoring of treatment
After starting treatment, & as indicated
If Bone Turnover Markers are available,
- Baseline : 2 separate measurements of same marker
- Follow-up : 1 repeat measurement
at 2-3 months at yearly intervals
Measurements should be taken at the same time of day to minimize effect of diurnal variation
Bone Turnover Markers
Bone Turnover Markers (BTMs) – can be used to evaluate treatment efficacy28,29,30
Changes in level of BTM can be seen within 3-6 months after initiation of drug therapy26,27
(Grade B, Level IIa)
26. Lehtonen-Veromaa M, Möttönen T, Irjala K, et al. J Clin Endocrinol Metab 2000;85:3726–32
27. Kraenzlin ME, Seibel MJ, Trechsel U, et al. Calcif Tissue Int 1996;58:216-20
28 Raisz L, Smith JA, Trahiotis M, et al. Osteoporos Int 2000;11:615-20 29 Seibel MJ, Woitge HW, Farahmand I, et al. Exp Clin Endocrinol Diabetes 1998;106:143-8 30 Delmi M, Rapin CH, Bengoa JM, Delmas PD, Vasey H, Bonjour JP. Lancet 1990;335(8696):1013-6
Table 6: Currently Available Biochemical Markers – Bone Turnover Markers (BTMs)
How long to treat?
It is recommended to evaluate the efficacy of bisphosphonate therapy after 3-5years
If a lack of efficacy is noted, i.e. significant deterioration of BMD, or recurrent low trauma fracture occurs, re-evaluation is required to exclude the following:
Secondary causes of osteoporosis
Drug compliance
If the above have been excluded, bisphosphonates can either be continued or an alternative therapy can be considered (i.e. anabolic therapy)
How long to treat?
When prescribing bisphosphonates for longer than 5 years, evaluation of the need for continued bisphosphonate therapy is recommended.
In patients:
with low risk of fracture, consider a drug holiday
with evidence of atypical femoral shaft fracture, bisphosphonate therapy should be discontinued
with high risk of fracture, consider continuing bisphosphonate therapy up to 10 years
Conclusions
Patients with a prior fragility / osteoporotic fracture, or osteoporosis on DXA measurement, need to be treated
The therapeutic aim of treatment is to reduce fractures, rather than just to increase BMD
In the vast majority of cases, the benefit of treatment outweigh the small risk of adverse events
THANK YOU