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

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rdiz

ed a

nn

ua

l in

cid

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(ra

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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