osteoporosis: identification of high risk individuals leonard koh consultant physician &...
TRANSCRIPT
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Osteoporosis: Identification of High Risk Individuals
Leonard Koh
Consultant Physician & EndocrinologistGleneagles Medical Centre
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Scope
• Fracture risk in Asians
• Risk factors for osteoporosis
• Using risk factors for diagnosis
• Risk factors for fracture
• Using risk factors for treatment
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Scope
• Fracture risk in Asians
• Risk factors for osteoporosis
• Using risk factors for diagnosis
• Risk factors for fracture
• Using risk factors for treatment
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Regional distribution of hip fractures in women 65 years (%)
2050
20.9
Asia Europe N America Latin America
Russia Middle East Oceania Africa
31.2
28.6
7.1
8.82.3
0.80.2
51.1
13.0
11.9
12.5
4.45.7 0.7 0.6
1990
Cooper, Osteoporos Int 1992;2:285
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Population Women
ASIANS• Singapore 1991-98 402• Singapore 1955-62 75• Malaysia 1997-98 199• Malaysia 1989 108• California 1983-84 337
CHINESE• Singapore 1991-98 410• Singapore 1957-63 106• Hong Kong 1997-98 429• Hong Kong 1966 149• Taiwan 1996-2000 451• Shenyang 1994 87• Beijing 1990-92 96
MALAY• Singapore 1991-98 264• Singapore 1957-63 44
INDIAN• Singapore 1991-98 361• Singapore 1957-63 565
Age-adjusted* hip fracture incidence rates per 100,000 in 50 year olds
* to 1985 US population
Population Women
JAPANESE• Wakamaya 1992 332• Tottori 1998-2001 304• Tottori 1986-87 206• Okinawa 1984-85 287• Hawaii 1979-81 247
KOREAN• Honam 2001 176• Honam 1991 41
THAI• Chiang Mai 1997-98 251
ARAB
• Kuwait 1992-95 295• Shiraz 2000-03 505
CAUCASIAN• California 1983-84 553• Hawaii 1979-81 579• Stockholm 1972-81 622
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Hip Fractures in Singapore 1991-1998
Koh, Osteoporos Int 2001:12:311-8** 50 year olds, standardized to 1985 US population
168
410
71
264
128
361
0
50
100
150
200
250
300
350
400
450 Chinese
Malay
Indian
Inci
den
ce r
ate
pe
r 1
00,0
00
**
(95%
co
nfid
enc
e in
terv
als)
Males Females
* p<0.05
* **
*
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Bone density & hip geometry in a multiracial population
Goh, J Clin Densitom 2004;7:406-412
• n=1575: Chinese 1222 (77.6%), Malays 122 (7.7%), Indian 231 (14.7%)• age 20-59 yr
* p < 0.05
0.941
0.879
0.967
0.888
0.9460.968
0.5
0.7
0.9
1.1
Chinese Malay Indian
20 - 29 yr 50 - 59 yr
Age group (yr)
Fe
mo
ral n
eck
BM
D (
g/c
m2) **
9.879.67 9.69
8
9
10
11
CH MA INH
ip a
xis
len
gth
(cm
)
*
*
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Borgstrom, Osteoporos Int 2006;17:1459-71
Hip fracture risk among women in the general population
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Barrett-Connor, JBMR 2005;20:185-94
Ethnic differences in fracture risk
National Osteoporosis Risk Assessment (NORA)
Mean T-score (SD) -0.89 -0.39 -1.12 -1.13 -1.22
Incidence of 1.5 0.8 1.8 1.7 0.7all fractures (%)
1 0.55 0.96 1.2 1.051 0.52 0.87 0.95 0.320
0.2
0.4
0.6
0.8
1
1.2
1.4
Caucasian African-American
NativeAmerican
Hispanic-American
Asian-American
Odds of osteoporosis
Relative risk of fracture
Odd
s /
Rel
ativ
e ris
k
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Falls among Asian vs Caucasian women
Davis, J Clin Epidemiol 1997;50:589-94. Aoyagi, J Bone Miner Res 1998;13:1468-74
Reference Population Risk ratios (95% CI)
Prudham 1981 65 yr+, Northeast UK 1.8 (1.6-2.1)
Blake 1988 65 yr+, Nottingham UK 2.2(1.9-2.6)
Wickham 1989 65 yr+, National UK 2.2 (1.9-2.6)
Winner 1989 Postal survey, Oxford, UK 1.4 (1.1-1.7)
Campbell 1989 70 yr+, New Zealand 1.8 (1.5-2.2)
O’Loughlin 1993 65 yr+, Montreal, Canada 1.4 (1.1-1.8)
Lukinen 1994 70 yr+, Finland 1.8 (1.4-2.1)
Davis 1997 Japanese, Hawaii, USA 0.8 (0.6-1.1)
Aoyagi 1998 65 yr+, Mitsui-gun, Japan 1.0
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Costs of osteoporosis
• Mortality
• Morbidity
• Economic
• Social
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Scope
• Fracture risk in Asians
• Risk factors for osteoporosis
• Using risk factors for diagnosis
• Risk factors for fracture
• Using risk factors for treatment
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Definition
NIH Consensus Development Panel 2001
Osteoporosis:bone disorder
Reducedbone strength
Increasedfracture risk
Bone density
DXA hip & spine
+ Bone quality
?
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Kung, J Bone Miner Res 2007;22:1080-7
Ten-year probability of osteoporotic fractures in Chinese women according to risk factors & BMD
• 1435 community dwelling, post-menopausal women• Mean age 63 years
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Bone mass life-line
0 10 20 30 40 50 60 70
BO
NE
MA
SS
Full genetic potential Menopause
Inadequate environmental factors High fracture risk
AGE
modified from Heaney, Osteoporos Int 2000
HEREDITY
EXERCISE / LOADING
CALCIUM & VIT D INTAKE
STRUCTURAL ERRORS
Increased bone loss
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Determinants of BMD
Pre-menopausal Post-menopausal p
Subject number 262 269 -
Age (yr) 33 65 <0.0001
Height (cm) 159 152 <0.0001
Weight (kg) 54 55 ns
Age at menarche (yr) 13 15 <0.0001
Age at menopause (yr) - 49 -
Calcium intake (mg/d) 605 635 ns
Isoflavone intake (mg/d) 33 25 ns
Smoker % 4 3 ns
Drinker % 7 1 <0.05
Physical activity score 3.4 3.5 ns
LS BMD (g/cm2) 0.977 0.733 <0.0001
FN BMD (g/cm2) 0.744 0.597 <0.0001
Lau, Bone 2005;36:700-9
ER, ER, CASR, COLIA1, LRP5, VDR
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Premenopausalwomen
Postmenopausalwomen
Determinants of BMD
Lau, Bone 2005;36:700-9
80.6
15.9
3.5
Weight
Genetic
Age
Menarche age
Calcium intake
Others4.4
2.2
25.1
68.3
LS BMD LS BMD
24.3
75.7
14.158.8
23
1.10.7
FN BMD FN BMD
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Factors affecting bone mass
Other (weight, medication, etc)
Exercise
Calcium deficiencyHeredity
Heaney, AJCN 1991 Pocock JCI 1987, Pocock JCI 1986, Kelly BMJ 1990
Specker, Am J Clin Nutr 2000
Heredity75-80%
Diet40%
Exercise40% Other (weight,
medication, etc)
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Scope
• Fracture risk in Asians
• Risk factors for osteoporosis
• Using risk factors for diagnosis
• Risk factors for fracture
• Using risk factors for treatment
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Risk factors for low bone mass & fracture:� Personal history of fracture as an adult� History of fracture in a first degree relative (especially maternal)� Low body weight & older age � Early natural or surgical menopause (< 45 yr), prolonged amenorrhea >1 yr� Drugs e.g. corticosteroids, excess thyroxine, anticonvulsants� Ongoing disease e.g. hypogonadism, rheumatoid arthritis, malabsorption� Prolonged immobilization, poor health or frailty� Current cigarette smoking� Alcohol abuse� Lifelong low calcium intake � Lack of regular physical activity
Risk factors for fracture independent of bone mass:� Previous falls in the past year� Strokes, poor balance, weak quadriceps muscle strength� Impaired eyesight despite adequate correction� Drugs e.g. sedatives, polypharmacy� Environmental factors e.g. slippery floors, inadequate lighting
Risk Factors for Osteoporosis
MOH CPG 2002
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Measure BMD
More risk factors for osteoporosis
More likely to have osteoporosis
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Bone densitometry indications Prevalence (%)Prolonged amenorrhea <1Late puberty after age 15 yr 5.6Menopause before age 45 yr 19.2Menopause after age 45 yr with 2 or more additional risk factors 44.1 (No HRT, FHx OP, BMI<25, cigarettes>10/d, alcohol>4 glasses/d,
physical activity<30 min/d, low calcium diet)Hypogonadism <1History of non-traumatic fractures <1Fortuitous discovery of osteopenia <1History of diseases affecting the skeleton 6.9History of long-term immobilization (>3 mth) <1Long-term use of medication affecting the skeleton 12.8
Use of risk factors in screening for osteoporosis
• n =3,998, female 92%, age ~60 yr
• Prevalence of osteoporosis: FN 23%, LS 23%, any site 31%
Ben Sedrine, Osteoporos Int 2002;13:434-442
Presence of at least one risk factor 66.6
Probability of having osteoporosis with at least one risk factor : 35%
Probability of having osteoporosis with 2 or more risk factors : 36%
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Year Instrument Factors used in scoring system
1992 Ribot et al age, wt, ht, age at menarche, menopause, yr since menopause, OA
1998 NOF age 65 or age <65 & one of: low wt, # after age 40, FHx #, smoking
1998 SCORE age, wt, race, RA, # after age 45, estrogen
1998 SOFSURF age, wt, smoking, # after age 50
2000 ORAI age, wt, no estrogen
2000 ABONE age, wt, never estrogen
2001 OSTA / OST age, wt
2002 OSIRIS age, wt, prior #, estrogen
2004 DOEScore age, wt, prior #
Scoring systems to select postmenopausal women for BMD
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Osteoporosis Self-assessment Tool for Asians
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85-89
45-49 50-54 55-59 60-64 65-69 70-74 75-7940-44
Weight (kg)
Age(yr)
LOW RISK*probability 1 - 3%
HIGH RISK*probability 46 - 61%
MODERATE RISK*probability 10 - 15%
* probability of finding osteoporosis on BMD
Koh, Osteoporos Int 2001;12:699
RISK FACTORS
� Previous fracture
� Family history of fracture
� Poor health & frailty
� Cigarette smoking
� Early menopause
� Alcohol abuse
� Prolonged immobilization
� Drugs e.g. corticosteroids
� Ongoing disease
Send for DXA+ risk factors
Truncate [Weight (kg) x 0.2] – Truncate [Age (yr) x 0.2]Truncate 0.2 x [Weight (kg) – Age (yr)]
-1
-2
-3
-4
-5
-6
0 1 3 4 5 62
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Osteoporosis Self-Assessment Tool (OST) Validation
Author Study population Cut-offs Low risk Medium risk High risk
Koh 2001 8 Asian countries -1, -4 3 15 61
Japan -1, -4 1 10 44
Koh 2001 Singapore -1, -4 1 10 46
Saetung 2008 Thailand -1, -4 2 6 40
Geusens 2002 USA multicentre 1, -3 4 23 57
Rotterdam 1, -3 4 22 57
Richy 2004 Belgium 1, -3 6 22 60
Cadarette 2004 Canada (chart) 1, -3 4 17 58
Canada (equation) 1, -3 2 19 56
Gourlay 2005 Belgium (45-64 yr) 3, -2 1 6 28
Belgium (65 yr) 1, -5 3 16 57
Percent with osteoporosison FN BMD (%)
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What OSTA/OST does and does not do
Guides decision to do BMD
Does not guide lifestyle decisions
Does not guide decision to treat
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van Staa, Q J Med 2006;99:673
THIN index
FRACTURE index
Rotterdam risk score
Body weight criteria
ORAI
OST
Clinical score for estimating 5-year hip fracture risk
Risk factors for THIN index:Age, fracture history, fall history, BMI, smoking,chronic disease, CNS meds, early menopause
“A simple scheme that only included age and weight (the Osteoporosis Self-Assessment Tool) found (hip) fracture risks similar to our more complex scheme.”
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Prevalence of vertebral deformities according to OSTA index group
Saetung, J Bone Miner Metab 2008;26:47
19.2
7.9
2.8
0
2
4
6
8
10
12
14
16
18
20
High risk Medium risk Low risk
Pre
vale
nce
(%)
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Scope
• Fracture risk in Asians
• Risk factors for osteoporosis
• Using risk factors for diagnosis
• Risk factors for fracture
• Using risk factors for treatment
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Risk factors for hip fracture in women
Asian Osteoporosis Study
• (451 men) & 725 women with hip fractures• Age 50 yr and over• Singapore, Malaysia, Thailand, Philippines
Risk factor Risk ratio (95% CI)
Dietary calcium intake
Highest quartile 1.0
Lowest 3 quartiles (<498 mg/d) 2.0 (1.5-2.8)
Load-bearing activity in immediate past
Everyday 1.0
Weekly 1.1 (0.7-1.7)
None 2.0 (1.4-2.7)
Vigorous sports activity at 25-49 yr (no vs yes) 7.2 (4.0-13.0)
Smoking (Ex- or current vs non-) Not included
Alcohol (7 days/wk vs non-) 2.9 (1.0-8.6)
Lau, JBMR 2001;16:572-80
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Risk factors for hip fracture in women
Risk factor Risk ratio (95% CI)
Falls in last 12 months: None 1.0
Once 1.4 (0.9-2.1)
Twice or more 3.0 (1.8-4.8)
History of fractures from age 50 yr (yes vs no) 1.8 (1.1-2.9)
History of stroke (yes vs no) 3.8 (2.0-7.1)
Drug history: Sedatives 2.5 (1.0-6.3)
Thyroid drugs 7.1 (2.0-25.9)
Body height quartile:
highest (men ≥1.69m, women ≥1.56m) vs
lowest (men <1.59m, women <1.48m) 2.0 (1.3-3.0)
Age at menopause 1.5 (1.0-2.1)
Lau, JBMR 2001;16:572-80
Asian Osteoporosis Study
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Kung, J Bone Miner Res 2007;22:1080-7
Ten-year probability of osteoporotic fractures in Chinese women according to risk factors & BMD
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Scope
• Fracture risk in Asians
• Risk factors for osteoporosis
• Using risk factors for diagnosis
• Risk factors for fracture
• Using risk factors for treatment
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Definition BMD T-score Action
Normal -1 SD Repeat BMD after a time interval
Osteopenia -1 to -2.5 SD Consider prevention. With multiple risk factors: consider treatment
Osteoporosis -2.5 SD Consider treatment
Severe Osteoporosis
-2.5 SD + fracture Advisable to treat
Most guidelines*
Treatment based on BMD & Fractures
* NOF, AACE, EFFO, UK, Australian, Singapore, Malaysia
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Definition BMD T-scoreat baseline
Treatments shown to reduce vertebral fractures
Normal -1 SD nil
Osteopenia -1 to -2.5 SD• Unselected• <-1.5 SD
HRT** RLX, STR
Osteoporosis -2.5 SD, no fracture ALN*, RIS*, RLX, STR
Severe osteoporosis Vertebral fracture ALN**, RIS**, ZOL**, STR**, RLX, PTH*, HRT*, IBNETI, CTN, PAM
Results of Treatment Trails by BMD & Fractures
Multiple clinical riskfactors for fracture
If BMD not known nil
* also reduce non-vertebral fractures** also reduce non-vertebral and hip fractures
Subgroup:elderly, osteoporotic
-2.5 SD, no fracture, Age 80 yr
STR*, RIS, PTH
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Wainwright, J Clin Endocrinol Metab 2005;20:1185-94
Hip fracture and BMD
Study of Osteoporotic Fractures
54% of women with incident hip fractures (n=243) did not have
osteoporosis
17% of women (n=8065)had osteoporosis
Proportion with
fractures 8.2%
Proportion with fractures
2.0%
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Better way to assess fracture risk?
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2.4
3.2
4.3
4.6
4.0
2.6
4.2
4.5
1.8
3.0
4.1
5.5
6.0
5.0
3.3
5.4
5.8
2.3
3.8
5.1
7.1
7.7
6.3
4.1
7.0
7.4
2.8
4.7
6.5
9.0
9.9
8.0
5.3
9.1
9.4
3.5
5.9
8.2
11.5
12.7
10.0
6.7
11.8
12.0
4.3
7.4
10.4
14.6
16.2
12.6
8.5
15.2
15.3
5.6
9.2
13.0
18.3
20.5
15.6
10.7
19.4
19.1
6.6
11.3
16.2
22.8
25.6
19.3
13.4
24.5
23.8
8.1
14.1
20.2
28.4
31.8
23.9
16.8
30.8
29.4
10.0
21.3
30.6
42.3
46.4
35.5
26.0
46.2
42.7
15.0
2.4
3.2
4.3
4.6
4.0
2.6
4.2
4.5
1.8
3.0
4.1
5.5
6.0
5.0
3.3
5.4
5.8
2.3
3.8
5.1
7.1
7.7
6.3
4.1
7.0
7.4
2.8
4.7
6.5
9.0
9.9
8.0
5.3
9.1
9.4
3.5
5.9
8.2
11.5
12.7
10.0
6.7
11.8
12.0
4.3
7.4
10.4
14.6
16.2
12.6
8.5
15.2
15.3
5.6
9.2
13.0
18.3
20.5
15.6
10.7
19.4
19.1
6.6
11.3
16.2
22.8
25.6
19.3
13.4
24.5
23.8
8.1
14.1
20.2
28.4
31.8
23.9
16.8
30.8
29.4
10.0
21.3
30.6
42.3
46.4
35.5
26.0
46.2
42.7
15.0
Kanis, Osteoporos Int 2001;12:989-95
Ten-year probability of any osteoporotic fracture (hip, spine, forearm, humerus) according to BMD
Swedish women
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
BMD T-score
50
60
70
80
65
55
75
85
45
Ag
e (y
r)
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Age-adjusted* hip fracture incidence rates per 100,000 in 50 year olds
Population Women
JAPANESE• Wakamaya 1992 332• Tottori 1998-2001 304• Tottori 1986-87 206• Okinawa 1984-85 287• Hawaii 1979-81 247
KOREAN• Honam 2001 176• Honam 1991 41
THAI• Chiang Mai 1997-98 251
ARAB• Kuwait 1992-95 295• Shiraz 2000-03 505
CAUCASIAN• California 1983-84 553• Hawaii 1979-81 579• Stockholm 1972-81 622
Population Women
ASIANS• Singapore 1991-98 402• Singapore 1955-62 75• Malaysia 1997-98 199• Malaysia 1989 108• California 1983-84 337
CHINESE• Singapore 1991-98 410• Singapore 1957-63 106• Hong Kong 1997-98 429• Hong Kong 1966 149• Taiwan 1996-2000 451• Shenyang 1994 87• Beijing 1990-92 96
MALAY• Singapore 1991-98 264• Singapore 1957-63 44
INDIAN• Singapore 1991-98 361• Singapore 1957-63 565
* to 1985 US population
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International variations in hip fracture probabilities
Kanis, J Bone Miner Res 2002;17:1237-44
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1.5
2.0
2.7
2.9
2.5
1.6
2.6
2.8
1.1
1.9
2.5
3.4
3.7
3.1
2.0
3.3
3.6
1.4
2.4
3.2
4.4
4.8
3.9
2.5
4.3
4.6
1.7
2.9
4.0
5.6
6.1
5.0
3.3
5.6
5.8
2.2
3.7
5.1
7.1
7.9
6.2
4.2
7.3
7.4
2.7
4.6
6.4
9.1
10.0
7.8
5.3
9.4
9.5
3.5
5.7
8.1
11.3
12.7
9.7
6.6
12.0
11.8
4.1
7.0
10.0
14.1
15.9
12.0
8.3
15.2
14.8
5.0
8.7
12.5
17.6
19.7
14.8
10.4
19.1
18.2
6.2
13.2
19.0
26.2
28.8
22.0
16.1
28.6
26.5
9.3
Extrapolation for Singapore women
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
BMD T-score
50
60
70
80
65
55
75
85
45
Ag
e (y
r)
1.5
2.0
2.7
2.9
2.5
1.6
2.6
2.8
1.1
1.9
2.5
3.4
3.7
3.1
2.0
3.3
3.6
1.4
2.4
3.2
4.4
4.8
3.9
2.5
4.3
4.6
1.7
2.9
4.0
5.6
6.1
5.0
3.3
5.6
5.8
2.2
3.7
5.1
7.1
7.9
6.2
4.2
7.3
7.4
2.7
4.6
6.4
9.1
10.0
7.8
5.3
9.4
9.5
3.5
5.7
8.1
11.3
12.7
9.7
6.6
12.0
11.8
4.1
7.0
10.0
14.1
15.9
12.0
8.3
15.2
14.8
5.0
8.7
12.5
17.6
19.7
14.8
10.4
19.1
18.2
6.2
13.2
19.0
26.2
28.8
22.0
16.1
28.6
26.5
9.3
Relative probability for Singapore = 0.62
Ten-year probability of any osteoporotic fracture (hip, spine, forearm, humerus) according to BMD
Based on Swedish data
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Kung, J Bone Miner Res 2007;22:1080-7
Ten-year probability of osteoporotic fractures in Chinese women according to risk factors & BMD
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1.5 1.9 2.4 2.9 3.7 4.6 5.7 7.0 8.7 13.2
2.0 2.5 3.2 4.0 5.1 6.4 8.1 10.0 12.5 19.0
2.7 3.4 4.4 5.6 7.1 9.1 11.3 14.1 17.6 26.2
2.9 3.7 4.8 6.1 7.9 10.0 12.7 15.9 19.7 28.8
2.5 3.1 3.9 5.0 6.2 7.8 9.7 12.0 14.8 22.0
1.6 2.0 2.5 3.3 4.2 5.3 6.6 8.3 10.4 16.1
2.6 3.3 4.3 5.6 7.3 9.4 12.0 15.2 19.1 28.6
2.8 3.6 4.6 5.8 7.4 9.5 11.8 14.8 18.2 26.5
1.1 1.4 1.7 2.2 2.7 3.5 4.1 5.0 6.2 9.3
50
60
70
80
65
55
75
85
45
Age
(yr
)
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
BMD T-score
50
60
70
80
65
55
75
85
45
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
BMD T-score
Extrapolated fromKanis, Osteoporos Int 2001;12:989-95 Kung, J Bone Miner Res 2007;22:1080-7
Ten-year probability of any osteoporotic fracture according to age and BMD
Hong KongExtrapolation for Singapore
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Relevant databases for Asians:• China• Japan• US (Asian)
http://www.shef.ac.uk/FRAX/index.htm
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Fracture risk for countries other than US
(Asian), Japan & China?
What threshold for intervention?
Are osteoporosis drugs effective based on
clinical fracture prediction models?
Issues
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Age
(yr
)
BMD T-score
50
60
70
80
65
55
75
85
45
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
BMD T-score
Hong KongExtrapolation for Singapore
50
60
70
80
65
55
75
85
45
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
50
60
70
80
65
55
75
85
45
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
50
60
70
80
65
55
75
85
45
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
FRAX (Japan)FRAX: US (Asian)
Age
(yr
)
Wt 54.9 kgHt 152 cm
Any fracture
10%
15%
20%
Any fracture
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Absolute 10-year hip fracture risk (vertical bars) at which it is cost-effective to treat (lines) in the USA
Tosteson, Osteoporos Int 2008;19:437-47
0
3
6
9
12
15
50 60 70 80
Age (yr)
10-
yr H
ip F
ract
ure
Pro
bab
ility
, %
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Tosteson, Osteoporos Int 2008;19:437-47
Cost-effectiveness thresholds for US white women based on treatment cost and willingness-to-pay (per QALY gained)
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Age
(yr
)
BMD T-score
50
60
70
80
65
55
75
85
45
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
BMD T-score
Hong KongExtrapolation for Singapore
50
60
70
80
65
55
75
85
45
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
50
60
70
80
65
55
75
85
45
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
50
60
70
80
65
55
75
85
45
+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0
FRAX (Japan)FRAX: US (Asian)
Age
(yr
)
Wt 54.9 kgHt 152 cm
Hip fracture
2%
3%
5%
Any fracture
10%
15%
20%
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• Fracture incidence is rising in Asians
Conclusions
• Epidemiological differences in hip fracture risk exist between Asians and other races, and within Asian ethnicities
• Risk factors for low BMD appear similar to other populations, but many occur in a minority
• Risk factors for low BMD could be used in clinical scoring systems as part of screening strategies for detecting osteoporosis
• Risk factors for fracture appear similar to other populations, are quantifiable, and have been used in models to predict 5- to 10- year fracture risk to assist in treatment decisions
• These models need to be tailored for each country
• There are limitations in BMD-based treatment algorithms