MISSION OSTEOPOROSIS ARMENIA

THE FIRST DECADE: 2007-2017 Gaining awareness and getting results:

John P. Bilezikian, M.D.

Professor of Medicine and Pharmacology

Vice-Chair for International Education and Reseach

Director, Metabolic Bone Diseases Program

College of Physicians and Surgeons

Columbia University, New York, NY USA

ARMENIAN HERITAGE CRUISE

January 21, 2017

John P. Bilezikian, M.D.

Disclosures:

Amgen (Consultant, Advisory Board)

Shire Pharmaceuticals (Consultant)

Radius Pharmaceuticals (Advisory Board)

1//17

Outline

• Background- Osteoporosis in the world

• Inspiration for applying knowledge to

Armenia

• What we knew in 2007

• What we accomplished

• Where we are going

Osteoporosis

A GLOBAL PROBLEM

Projected Number of Hip Fractures

Projected to reach 3.250 million in Asia by 2050

Adapted from Cooper C et al. Osteoporosis Int. 1992;2:285-289.

Estimated no. of hip fractures: (1000s)

1950 2050

600

3250

1950 2050

668

400

1950 2050 742

37

8

1950 2050

100

62

9

Total number of

hip fractures:

1950 = 1.66 million

2050 = 6.26 million

Osteoporosis: Worldwide Prevalence

Affects 200 million women

worldwide1

- 1/3 of women aged 60 to 70

- 2/3 of women aged 80 or older

Approximately 30 % of women over

the age of 50 have one or more

vertebral fractures2

1. International Osteoporosis Foundation Osteoporos Int 1996, 6:233 2. Dennison,2000

• A hip fracture occurs on

average every 30

seconds, somewhere in

the world!

The key epidemiological message:

“Osteoporosis is one of the most dangerous diseases of the 21st century*”

*Narine Mamikonyan, Armenian Osteoporosis

Association, 2015

Shuler FD, et al. Orthopedics 2012;

35:798-805

Melton LJ, et al. J Bone Miner Res 1992;7:1005-10.

Looker AC, et al. J Bone Miner Res 1997;12:1761-8.

National Osteoporosis Foundation. 1998, 2002.

Burge et al. J Bone Miner Res, 2007

Postmenopausal Osteoporosis

in the United States

• 2.0 Million Fractures Annually in the United States

• 40-50% life time risk in a typical 50 year old

Caucasian woman

• Fractures occur at 3 main sites:

Vertebral: 15.6%

Hip: 17.5%

Forearm: 16.0%

Postmenopausal Osteoporosis

in Armenia

• Data relative to fractures in

Armenia have become

available in the past year

Ross PD et al. Ann Intern Med 1991;114-23.

Silverman SL. Bone 1992;13 (suppl 2):S27-31.

Cooper C, et al. Am J Epidem 1993;137:1001-5.

Lyles et al. Am J Med 1993;94:595-601.

Schlaich C, et al. Osteoporos Int 1998;8:261-7.

Human Costs of Osteoporosis

• Impaired function, decreased mobility

• More bone loss due to decreased activity

• Compressed abdomen,

reduced appetite

• Reduced pulmonary

function

• Sleep disorders

• Shortened survival

• Poor self esteem

Photo courtesy of the National Osteoporosis Foundation

28-32,000,000

10-12,000,000

Men

Women

14

Osteoporosis: Identifying the Problem

“ A skeletal disorder

characterized by

compromised

bone strength

predisposing to an

increased risk of

fracture.”

Healthy bone

Osteoporotic bone

NIH Consensus Development Conference on Osteoporosis, 2000.

Adapted from Wasnich RD, et al. Osteoporosis: Critique and Practicum. 1989:179

Bone Loss

Begins in 30s (women), late 40s (men)

Accelerates at menopause due to estrogen deficiency

Continues throughout life

Influenced by other factors: nutrition, diseases, medications, lifestyle, etc

10 20 30 40 50 60 70 80 90

Bo

ne M

ass

Active

Growth

Slow

Loss

Continuing

Loss ME

NO

PA

US

E

Age

Women Men

Pathogenesis of Osteoporosis and

Fractures

Figure reprinted from National Osteoporosis Foundation, Physician’s Guide to Prevention and Treatment of Osteoporosis.

Modified from Riggs BL, Melton LJ. Osteoporosis: Etiology, Diagnosis, and Management. New York: Raven Press; 1988.

MENOPAUSE AGING OTHER RISK FACTORS

PROPENSITY

TO FALL

LOW PEAK

BONE MASS

POOR BONE

QUALITY

INCREASED

BONE LOSS

LOW BONE

DENSITY

FRACTURES

Before 1986, osteoporosis was diagnosed by

clinical appearance or the fragility fracture

In 1986….

• Dual energy X-ray Absorptiometry (DXA) became available as a clinical tool to assess bone mineral density in the setting of clinical medicine…..

• It changed the way we think about and the way we diagnose osteoporosis

Features of Bone Densitometry by DXA

• Safe

• Accurate

• Precise

• Normative population

databases

• Correlates with fracture risk

• A diagnostic standard

• An important aspect of FRAX

risk assessment system

HOLOGIC

• Central DXA is the gold

standard for diagnosis

• Measures the most

important fracture sites

(hip and spine)

• Can be used to monitor

response to therapy

Hologic

GE Lunar

Central DXA Bone Density Measurements

Norland

NOF Clinician’s Guide to Prevention and Treatment of Osteoporosis . 2013. www.nof.org .

Correlates with life time fracture risk for Caucasian Women

-4.0 -3.5 -3.0 -2.5 -2.0 -1.5 -1.0 -0.5 0 +0.5 +1.0

Interpreting T-scores (WHO)

T-score

Osteoporosis

Normal

Bone Mass Low

Bone Mass

(Osteopenia)

UNITED STATES GUIDELINES FOR BONE DENSITOMETRY TESTING

Women

NOF1/AACE2

Men 3ISCD, 4TES

Age >65 >703

Fragility fracture YES YES

Starting steroids YES YES

Other risk factors

> 50 but <65 if

• Weight <127 lbs

• Early menopause

• Smoking

• FH of fracture

• Other Causes

> 50 but < 70 if

• Low weight ?

• Low T

• Smoking

• FH of fracture

• Other causes

1 National Osteoporosis Foundation 2 AACE 3 ISCD, 2010, 4Watts et al, 2012

ARMENIA: GUIDELINES FOR BONE DENSITOMETRY TESTING

Women

Men

Age ???? ????

Fragility fracture ???? ????

Starting steroids ???? ????

Other risk factors

????

????

With DXA… .Osteoporosis can be

identified before the fracture occurs

and plans for prevention and

treatment can be implemented

In 2007, 20 years after DXA became widely

used throughout the world…

• There was 1 DXA machine in Armenia!

The case to make available bone density

density testing in Armenia was clear in 2007…

• But where did the inspiration to do

something come from?

• Edgar Housepian

When the plane lands…..

The case to make available bone density

density testing in Armenia was clear in 2007…

• But where did the inspiration to do

something come from?

• Edgar Housepian

• Aram Chobanian

• Family

FAMILY

• Pauline and Armen Barooshian

• Sophie Bilezikian

• Diana Bilezikian

• Caroline Apovian

• Other relatives who have accompanied me over the past 10 years to Yerevan!

ZABELLE APOVIAN BILEZIKIAN

DXA in Armenia since 2007 2007: DXA placed at Markarian

2008: Ultrasound densitometer, YSMU

2009: DXA placed at YSMU

2010: Major software upgrades to all DXA

equipment

2011-1014: DXA units placed in

Erebouni Hospital

Traumatology and Orthopedic Hospital

Gyumri

Stepanakert (Karabagh)

2016: DXA units placed in Vanadzour and

in Kapan

Historical View

• By 2017, Armenia has acquired

enough DXA instruments, through

the generosity of the Hologic

Corporation in the United States, to

be placed as above average in rankings for instruments per capita in the world!

We brought technology and thus capabilities to diagnose osteoporosis in Armenia ... but how does one teach physicians in Armenia whose training is generally substandard and whose motivation is sometimes even less?

A broader view of education in Armenia (it’s not just osteoporosis)

• Medical Education in Armenia

– Needs identified during the

Housepian/Chobanian initiatives in

the early 2000s:

– Needs to address:

• Teaching methods

• Educational requirements

• Credentialing system

• Postgraduate education for specialty

certification

The years of Dr. Gohar Kyalyan Former Rector of Yerevan State Medical

University (2006-2010)

• In collaboration with Aram

Chobanian (President Emeritus of

Boston University) and the late

Edgar Housepian

• Change happened!

The Kyalyan years circa 2006-2010

• Official affiliation between YSMU

and Boston University and between

YSMU and Columbia University

• The entire medical curriculum of

BU was made available to all

medical students at YSMU

• International Advisory Committee

established

The Kyalyan years

• The Bologna system of medical

education implemented: updated

course and teaching methods

• Credentialling examinations

• More rigorous admission and

retention policies

Beyond those years

• Pace of progress has continued with

recognition by subsequent Rectors that

there is much to be done

• Good working relationships with Former

Rector Mikayel Naramanyan

• Active involvement of the American

University of Armenia (Armen Der

Kiureghian, President)

Back to Mission Osteoporosis

Training and Education

• Radiologists were trained by a Hologic application specialist (Larry Mowat) in all aspects of the DXA instrument, prior to using the instrument

• A “hot line” enables them to contact Hologic if any problems arise

• A Hologic-trained engineer is a full-time employee at Ereubuni Hospital and, thus, is available to service and make needed repairs whenever necessary

Training and Education

• Educational symposia for physicians and other health care professionals have been conducted yearly for the past 10 years

• The Tenth Symposium was held on October 6, 2016

The Osteoporosis Education Army: from the United States, UK, and Russia:

• Mariam Manoukian Tammy Martin

• Samuel Badalian Elena Sagayan

• Caroline Apovian Kim Hekimian

• Sara Takii Nicholas Hutchings

• John Kanis Richard Deckelbaum

• Larry Mowat Bob Bagramian

• Olga Lesynak

• Noune Pashinian

• Hasmik Arzumanyan

and from Armenia….

• Nara Mamikonyan Varduhi Petrosyan

• Gevorg Yachjyan Georgy Okoev

• Armine Horoyan Varta Babalyan

• Karine Arustamyan Bagrat Lalalyan

• Yelena Aghajanova Khoren Hovhannisyan

• Ani Akopyan Artashes Grigoyan

• Sargis Sahakyan Vachagan Ayvazyan

• Nara Aslanyan

• Siranoush Karagoshian

Supporting Organizations

Columbia University

Boston University

Yerevan State Medical University

American University of Armenia

Fund for Armenian Relief (FAR)

JHM Foundation

Hovnanian Foundation

International Osteoporosis

Foundation

Supporting Organizations -2-

• Russian Osteoporosis Association

• Armenian Osteoporosis

Association

• Hologic Corporation

Osteoporosis Symposia in Armenia

2007-2016

• In 2007, the first symposium at

Markarian Hospital drew a capacity

audience of about 100 people

• In 2016, the 10th Annual

Osteoporosis Symposium at the

American University of Armenia

drew over 600 attendees!

10th International

6 October 2016

10th Annual Osteoporosis Symposium

Yerevan, 2016

Faculy

Tenth Annual Osteoporosis

Symposium for Physicians and Health

Professionals

OBJECTIVE:

To review and to provide updates on the

latest advances in osteoporosis, regarding:

epidemiology, causes, nutrition, risk factors,

and management

Topics to be covered

Public Health Initiatives

Premenopausal Osteoporosis:

The Perimenopausal woman

Nutrition and

Skeletal Health

Major issues in Osteoporosis

Thyroid Hormone and

Bone

Glucocorticoid- Induced

Osteoporosis

Armenian Osteoporosis Association

Diabetes and Bone Health Obesity and

Skeletal Health

Agenda

Lunch 12:45-13:45

Afternoon Workshops

13:45-15:15

MORNING 9:30-12:45

Welcome and

Introductions

Armenian Osteoporosis

Association

Public Health Issues

Medical Issues

Epidemiology

Nutrition and skeletal

Health

Thyroid and Iodine Deficiency

Nutrition and Physical Activity

Topics in Osteoporosis

Diabetes and Obesity

Rheumatology and

Osteoporosis

Perimenopausal Skeletal

Health

The steps to recognition of osteoporosis in Armenia: How is

Progress Assessed?

Acquisition of Capability to

Measure Bone Mineral Density

Education

Hosting an International Summit

Conference on Osteoporosis

International Osteoporosis Summit:

Central Asian and Eastern European

Countries

Armenian Osteoporosis Association

International Osteoporosis Foundation

Yerevan, Armenia

4 October 2016

International Osteoporosis Summit:

Participating Countries*

• Armenia

• Russia

• Belarus

• Georgia

• Kazakhstan

• Kyrgyz

• Moldova

• Uzbekistan

• Austria

• Czech Republic

• Hungary

• Poland

• Slovakia

• United States

*Regrets from Ukraine, Slovenia, Romania

International Osteoporosis Summit:

Participants and Acknowledgements*

• Armenia: Varta Babalyan, Karine

Arustamyan, Lena Aghajanova, Sargis

Sahakyan, Varduhi Petroysan, Armine

Haroyan, Gevorg Yaghjyan

• *Acknowledgements: Levon Altunyan,

Minister of Health (represented by Vartan

Vartazaryan (Minister of Hospital Health

Care)

International Osteoporosis Summit:

Participants • Russia: Olga Lesnyak,Olga Ershova, Olga Derevyanko, Evgeni

Zotkin

• Belarus: Emma Rudenka, Elena Rudenka, Alla Shepelkevich

• Georgia: Marina Tsagarely, Medea Kopaliani, Maya Santania, Yulia

Zedgenidze

• Kazakhstan: Gulzhan Gabdulina, Sholpan Isaeva, Chokan

Baymukchmedov, Laura Danyarova, Akmaral Nurbekova, Nurlan

Turdalin

• Kyrgyz: Olga Lobanchenko, Anara Mamazhunosova

• Moldova: Eugeniu Russu, Victor Cazac,Angela Chicu, Oxana

Odobescu

• Uzbekistan: Shakirova Munavvara, Nadira Alikhanova

International Osteoporosis Summit:

Participants

• Austria: Heinrich Resch, Gerold Holzer

• Czech Republic: Milan Bayer

• Hungary: Peter Lakatos

• Poland: Edward Czerwinski, Roman Lorenc

• Slovakia: Juraj Payer, Peter Vanuga, Peter Jackuliak

• United States: John P. Bilezikian, Nicholas Hutchings, Kim

Hekimian, Mariam Manoukian, Noune Pashinan,

International Summit: Armenia

4 October 2016

International Summit: Armenia

4 October 2016

The steps to recognition of osteoporosis in Armenia: How is

Progress Assessed?

Acquisition of Capability to

Measure Bone Mineral Density

Education

Awareness

5 Leadership Round Tables on

Osteoporosis in Armenia

• Gathering of the leading

governmental and society leaders

in Women’s Health in Armenia

• Purpose: to further emphasize the

importance of skeletal health,

nutrition and other issues in

Armenia

3rd Leadership

Round Table on Osteoporosis

5th Leadership Roundtable

5 October 2016

Key points of the leadership

discussion

Capability for bone density acquired over

the past 10 years

Doctors in Yerevan are more

knowledgeable about osteoporosis than

ever before

There is now sound epidemiological data

on fracture incidence in Armenia leading

to a country-specific FRAX

Key points of the leadership

discussion

The challenge now is to apply these advances to improve detection, evaluation, and treatment of patients who are at risk.

PROGRESS

Acquisition of Capability

Education

• Research

Ongoing Research in Osteoporosis in

Armenia

• Traumatology and Orthopedic

Hospital (Nicholas Hutchings,Khoren

Hovhassisyan, Artashes Grigoyan)

• Ereubuni Hospital (Sargis Sahakyan)

• Markarian (Karine Arustamyan)

• Yerevan State Medical University (Yelena Aghajanova)

• Armenian American Wellness Center (Zaha Sahradyan)

New Research being planned for 2016-2017

Iodine Deficiency and thyroid disease in Armenia

• Yerevan State Medical University (Yelena Aghajanova)

• American University of Armenia (Varduhi Petrosyan)

• Columbia University (Nicholas Hutchings,

John Bilezikian)

• Stanford University (Mariam Manoukian)

• Ministry of Health

• UNICEF and WHO

PROGRESS

Acquisition of Capability

Education

Research

Governmental

How do we get the word out and influence

governmental policy?

Ministry of Health: October 10, 2014

Ministry of Health

• Health priorities of former Minister

of Health: Dr. Muradyan

– Preventative Medicine

• Cardiovascular

• Oncology

• Diabetes

• Nutrition

• Osteoporosis

My vision for Armenia

– An Osteoporosis Center that will be a central referral program for the entire region

Varta Babalyan has been named the first full-time, salaried Director of the Osteoporosis Center of Armenia!

My vision for Armenia

– An Osteoporosis Center that will be a central referral program for the entire region

– A program of first rate and publishable research on the epidemiology, diagnosis, and treatment of osteoporosis

Development of a Fracture Risk Assessment Tool for Armenia (Lesynak,Sahakyan, Bilezikian, Hutchings, Manoukian et al. To be published in 2017)- My next lecture on the cruise!

My vision for Armenia

– An Osteoporosis Center that will be a central referral program for the entire region

– A program of first rate and publishable research on the epidemiology, diagnosis, and treatment of osteoporosis

– A program of research that extends into other areas of endocrinology such as thyroid disease, obesity, and diabetes

– Hutchings N, Bilezikian JP et al. Iodine nutrition in Armenia, 2017

My vision for Armenia (cont’d)

– Ongoing educational programs to keep physicians and other health-care professionals for Armenian Health Care Professionals and others in the region

– Armenia will become the center for referrals and for education throughout the region

My vision for Armenia (cont’d)

– Government-sanctioned guidelines for screening with DXA and for treating osteoporosis will be implemented

Lessons Learned in the First 10 Years…

• We can make a difference • It takes time to make a difference • It takes a lot of work to make a difference • As a result, the skeletal health of the

people of Armenia will be improved

• Armenia has the potential to become a center for Osteoporosis through the region

Lessons Learned in the First 10 Years…

Each of us doing what we do best leads to positive results, multiplied many times over

PROGRESS

Acquisition of Capability

Education

Research

Governmental

Shnorhagalutyun!