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Algorithm of
OSTEOPOROSIS
NICOLAAS C. BUDHIPARAMA, MD
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
• 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
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 Limitations
Derives 10-year probability of Not valid to monitor patients on
clinical event from measurable treatment
parameters
Only femoral neck BMD is considered
Internationally recognized and
validated Risk is “yes/no” – there is no
Based on data from multiple consideration of “dose”
cohorts (e.g., fractures, glucocorticoids,
smoking, alcohol)
Easily accessible on the
Not all risk factors are included (eg,
Internet or DXA software
risk of falling)
Helps identify patients who
need treatment Clinical judgment is required
Can be used to reassure low- Do patients with high FRAX scores
risk patients benefit from medication? (Unknown)
The role of FRAX for treatment
of osteoporotic fractures
• Reduce bone resorption by inhibiting action of osteoclasts
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
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
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