Epidemiology of Osteoporosis in KSA

Osteoporosis:Epidemiology, Management, Prevention

DefinitionOsteoporosis is a progressive, systemic skeletal disorder characterized by compromised bone strength that increases the risk of bone fragility and susceptibility to fracture.DefinitionBone strength primarily reflects the integration of bone density and bone quality

Epidemiology -WorldwideOsteoporosis is estimated to affect 200 million women worldwide approximately:One-tenth of women aged 60, One-fifth of women aged 70, Two-fifths of women aged 80 Two-thirds of women aged 90 Osteoporosis causes more than 8.9 million fractures annually, resulting in an osteoporotic fracture every 3 seconds

Epidemiology -WorldwideWorldwide, 1 in 3 women over 50 will experience osteoporotic fractures, as will 1 in 5 men

A prior fracture is associated with an 86% increased risk of any fracture Epidemiology Of Osteoporosis in KSA

50-59 yrs : 33.4% osteopenia 24.3% osteoporotic60-69 yrs : 27% osteopenic 62% osteoporotic70-80 yrs : 21.5 osteopenic 73.8% osteoporotic Osteoporosis in postmenopausal Saudi women using dual x-ray bone densitometry . MahmoudI. El-Desouki, SAUDI MEDICAL JOURNAL)6El-Douski,Saudi Med J Epidemiology Of Osteoporosis in KSA 483 post menopausal Saudi women in Riyadh with an average age of 55 yrs ( range 52-62 yrs): 42% had normal BMD 34% had osteopenia 24% had osteoporosis7Bottom-line Osteopenia and osteoporosis are common among postmenopausal Saudi women and should be considered as a matter of public health.The prevalence of osteoporosis is far more common in the country than its Western counterparts

PhysiologyShape and structure of bone are continuously renovated and modified by the processes of modelling and remodellingBone modellingBegins with the development of the skeleton during fetal life and continues until the end of the second decadeBone remodellingOccurs from fetal life through to skeletal maturity, It maintains the mechanical integrity of the skeleton by replacing old bone with new.This constant process of turnover enables the skeleton to release calcium phosphatePhysiology

In the adult skeleton, approximately 510% of the existing bone is replaced every year through remodellingThe maintenance of a normal, healthy, mechanically competent skeletal mass depends on keeping the process of bone resorption and formation in balance. Failure to match bone formation with bone resorption results in net bone loss. This is what occurs in osteoporosis, as a result of different causesRisk Factors of Osteoporosis:

Risk Factors of osteoporosis:

Risk Factors of osteoporosis:

Gain of bone Peak bone massThe peak bone mass is the amount of bone tissue present at the end of skeletal maturationIt is the difference between the amount accumulated at maturity and that lost with ageingIt is a major determinant of the risk of fracture due to osteoporosis. There is, therefore, considerable interest in exploring ways to increase peak bone massDeterminants of peak bone massHereditySexDietary Endocrine factors (gonadal sex hormones and adrenal androgens Exposure to risk FactorsDisorders impairing peak bone massAnorexia nervosa Exercise-associated amenorrhoea Delayed puberty

Clinical manifestations and Complications of Osteoporosis

Symptoms: may include Back pain, loss of height, kyphosisHowever, osteoporosis is a silent disease, as bone loss occurs without symptoms. There are no warning signs until a fragility fracture occurs.A fragility fracture is defined as any fracture that occurs as a result of minimal trauma or no identifiable traumaClinical manifestations and Complications

Osteoporosis- related fractures may occur in any bone but are most likely to occur at sites of low bone mass. The most typical sites of osteoporosis related fractures are the vertebrae, distal radius, proximal femur, and ribs.The morbidity of osteoporosis comes mainly from fractures and their potential complications.

Clinical manifestations and Complications

Vertebral compression fractures are associated with pain, deformity, disability, and increased mortality. The most serious consequences, are those associated with hip fractures. An average of 24 % of patients aged > 50 years die within one year after their fracture, and approximately half of the survivors will have a disability necessitating long- term care.Evaluation/Diagnosis.Optimal evaluation consists of:Establishing the diagnosis of osteoporosis on the basis of bone mass assessmentEstablishing the fracture riskDetermining the need for instituting therapy.History and a physical examination to evaluate fracture risks; should include assessment for loss of height and change in posture.Laboratory evaluation for secondary causes of osteoporosis when osteoporosis is diagnosed.

Osteoporosis Diagnosis:The Dual-energy X-ray Absorptiometry (DXA) report provides Bone Mineral content in a given area of Bone

This gives BMD in grams per square centimeter(g/cm2)World Health Organization Diagnostic Categories of BMDNormal bone massBMD within 1 standard deviation of the reference mean for young adults (T-score 1.0)Low bone mass (osteopenia)BMD of > 1.0 to < 2.5 standard deviations below the mean for young adults (T-score < 1.0 and > 2.5)OsteoporosisBMD 2.5 standard deviations below the mean for young adults (T-score 2.5)Severe or established osteoporosisBMD 2.5 standard deviations below the mean for young adults in the presence of one or more fractures

Establishing the fracture riskWHO fracture assessment tool (FRAX)The FRAX is a simple clinical tool developed by the WHO to evaluate fracture risk in patientsThe FRAX comprises of variables/risk factors.

Screening:

Is the systematic application of the test when it is assumed that people have no symptoms.

Recommendations for Osteoporosis screening: - Osteoporosis is common, costly associated with high morbidity and mortality- Easily detectable and highly treatable - DXA is safe screening test- Patients can be started on treatment and counselled regrading lifestyle changes Osteoporosis screening at PHCHigh risk or selective screeningPostmenopausal womenMen 50-59 years With one or more of the following: Fragility fracture after age 40 yearsVertebral fracture or low BMD identified on X-rayParental hip fractureHigh alcohol intakeCurrent smokingLow body mass index (less than 18.5 kg/m2)High risk medication use: i.e. prolonged glucocorticoid use)Rheumatoid arthritisOther disorders that lead to bone lossMen and women < 50 yearsWith one or more of the following:HypogonadismFragility fractureHigh risk medication useRheumatoid arthritisChronis inflame conditionsCushing diseasemalabsorption syndromeUncontrolled hyperthyroidismPrimary hyperthyroidismOther disorders associated with rapid bone loss/ fractureAll Men and Women > 60 yearsRefer for DXA Screening Determining the need for instituting therapyManagementAn important goal in the management of osteoporosis is to prevent the first fracture.A. Non- pharmacologic measures.Change lifestyle risk factors.Prevent fallsMaintain or improve mobilityIncrease weight bearing exercisesManagementB. Pharmacologic measures.Treat secondary causes of osteoporosis, and associated disordersTreat pain, discomfort and other associated morbidityIncrease bone mass. Drugs for osteoporosis primarily reduce bone turnover by inhibiting osteoclast activity. The selection of any of the drugs used for osteoporosis should be individualized based on the patient characteristics, efficacy, and health economics. There is no agent that is suitable for all patients, and clinical judgment should always be exercised. Referral for expert opinion is warranted

Management1. Calcium and Vitamin D:Should not be used as the sole treatment of osteoporosis, but rather as adjuncts to therapy.Improve bone density in postmenopausal women.Reduce risk of fractures in elderly women.Most effective in subjects with low calcium and vitamin D.Calcium:Premenopausal, men 50 yr (1500 mg/d)ManagementVITA MIN DPremenopausal, men 50 yr (1000 IU/d) An alternative to supplementation would include exposure to the sun for 1015 minutes every day, 23 times/ week.

Management2. Alendronate [ Drug Class: Bisphosphonates] -Approved for prevention and treatment of osteoporosis, including steroid induced osteoporosis, and osteoporosis in men.Improves BMD at spine and hipReduces vertebral fractures and non-vertebral fractures.Reduces hip fractures.Once weekly dose of 70 mg is as effective as daily dose of 10 mg.Fall Prevention and Hip ProtectorsNon-pharmacologic interventions directed at preventing falls and reducing their effect on fractures: Using hip protectors to absorb or deflect the impact of a fallExercise Removing any obstacles that may result in fallsWithdrawal of psychotropic medications

Prevention Initiatives should be directed at the following measures:Optimize nutrition in the youth to achieve high peak bone mass.Encourage adequate intake of calcium and Vitamin D.Identify and treat subjects with Vitamin D deficiency, especially children, females in the reproductive age group, and the elderly.Recommend regular weight bearing exercise.Avoidance of tobacco smoking and excessive alcohol intake.Prevention Assess every postmenopausal woman for risk of osteoporosis, and determine the need for diagnostic tests and prevention /treatment.Early treatment of causes of osteoporosis [e.g. thyrotoxicosis, smoking, hyperparathyroidism, others].Prevention and early treatment of osteoporosis of patients who are receiving high dose steroid therapy, or other drugs that contribute to osteoporosis.

Resources International Osteoporosis Foundation http://www.iofbonehealth.org/Saudi Guidelines for Osteoporosis Prevention and Treatment 2014Guidelines for Prevention and Management of Osteoporosis in Adults at KFSH&RC -20032015 Guidelines for Osteoporosis in Saudi Arabia: Recommendations from the Saudi Osteoporosis Society. Ann Saudi Med 2015; 35(1): 1-12