2-1. Osteoporose. Dr. P. Van Wettere Radiologie en medische beeldvorming

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1 2-1 Osteoporose Dr. P. Van Wettere Radiologie en medische beeldvorming

2 2-2 Osteoporose Definitie Incidentie, mortaliteit, morbiditeit, kost Diagnose Radiologie Botdensitometrie FRAX

3 FractureCascade History Asymptomatic in the prefracture phase 2-3

4 Prevent Vertebral Fracture Cascade 2-4 B/L 10YR 20YR

5 2-5 Definition of Osteoporosis A disease characterized by low bone mass and microarchitectural deterioration of bone tissue leading to enhanced bone fragility and a consequent increase in fracture risk. World Health Organization (WHO), 1994 Normal bone Osteoporosis

6 Pathogenesis of Osteoporotic Fracture 2-6 Low peak bone mass Postmenopausal Bone loss Age related bone loss LOW BONE MASS Other risk factors Non skeletal factors (propensity to fall) FRACTURE = Fall + Low BMD Poor bone quality (architecture) LOW BMD = PBM or Loss Adapted from Melton LJ & Riggs BL. Osteoporosis: Etiology, Diagnosis and Management Raven Press, 1988, pp

7 2-7 Determinants of Peak Bone Mass Genetics Nutrition PEAK BONE MASS years of age Hormones Lifestyle

8 2-8 OSTEOPOROSIS: THE SIZE OF THE PROBLEM

9 2-9 Osteoporosis is a Prevalent Disease Affects 200 million women worldwide 1-1/3 of women aged 60 to 70-2/3 of women aged 80 or older Approximately 20-25% of women over the age of 50 have one or more vertebral fractures 2 - United States: 25% 3 - Australia: 20% 4 - Western Europe: 19% 5 - Scandinavia: 26% 5 - Denmark: 21% 6 1. International Osteoporosis Foundation 4. Jones G et al., Osteoporos Int 1996, 6: Melton LJ 3rd et al., Spine 1997, 22:2S 5. O'Neill et al., J Bone Miner Res 1996, 11: Ettinger B et al., J Bone Miner Res 1992,7: Jensen GF et al., Clin Orthop 1982,166:75

10 2-10 Vertebral Fractures Most common fracture type Often silent Insidious, progressive nature Associated with deformity, height loss, back pain impaired breathing increased morbidity and mortality Predict future spine and hip fractures

11 Incidence Rates for Vertebral, Wrist & Hip Fractures in Women after Age Annual incidence per 1000 women Vertebrae Hip Wrist Age (Years) Wasnich RD, Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism. 4th edition, 1999

12 2-12 Osteoporotic Fracture Incidence 4,000 Women Men Incidence / 100,000 Person-Years 3,000 2,000 1,000 Vertebrae Hip Vertebrae Hip Forearm Forearm Age (Years) Cooper C. et al, Trends Endocrinol Metab 1992; 3:224

13 Incidence United States) of Osteoporotic Fractures ( Only 30% of morphometric vertebral fractures are clinically apparent 2-13 Annual Incidence 750, , , ,000 Clinically apparent 300, , , Vertebral (Morphometric) Hip Wrist Fracture Type Other

14 Osteoporotic Fractures in Women: Comparison with Other Diseases 2-14 Annual incidence x * hip forearm other sites vertebral * annual incidence all ages annual estimate women 29+ annual estimate women new cases, all ages Osteoporotic Fractures Heart Attack Stroke Breast Cancer Riggs BL, Melton LJ. Bone 1995 Heart and Stroke Facts, 1996, American Heart Association Cancer Facts & Figures, 1996, American Cancer Society

15 Projected Burden of Osteoporotic Hip Fractures Worldwide 2-15 Estimated number hip fractures (x1000) Total no. hip fractures 1990 = 1.66 million 2050 = 6.26 million 0 North America Europe Latin America Asia Adapted from Cooper C., Melton LJ, Osteoporos Int 1992, 2:285

16 Projected Number of Osteoporotic Hip Fractures Worldwide Projected to reach million in Asia by Total number of hip fractures: 1950 = 1.66 million 2050 = 6.26 million Estimated number of hip fractures: (1000s) Adapted from C. Cooper et al, Osteoporos Int. 1992; 2:285-9

17 OSTEOPOROSIS: MORTALITY & MORBIDITY 2-17

18 Cumulative Survival Probability WOMEN 1.0 MEN Survival probability Survival probability Age Age Center JR et al., Lancet 1999, 353:878 Dubbo Population Vertebral/Major Fractures Proximal Femur Fractures

19 Mortality Rates by Number of Prevalent Vertebral Fractures Mortality (per 1000 person-years) Number of Vertebral Fractures Kado DM et al., Arch Intern Med 1999,159:1215 P for trend < 0.001

20 Relative Risk of Death Following Clinical Fractures 2-20 Fracture Intervention Trial (FIT)* Any Symptomatic Non-spine Hip Spine Forearm Other Age-Adjusted Relative Risk (95% CI) *6459 postmenopau sal women ages years followed for an average of 3.8 years Cauley JA et al., Osteoporos Int 2000, 11:556

21 Clinical Consequences 2-21 Kyphosis Loss of height Bulging abdomen Acute and chronic pain Breathing difficulties, reflux and other GI symptoms Depression REDUCED QUALITY OF LIFE

22 2-22 Vertebral Fractures Substantially Increase the Risk of New Fragility Fractures Women with vertebral fractures have a 5-fold increased risk of a new vertebral fracture and a 2-fold increased risk of hip fracture Black et al., J Bone Miner Res 1999 Melton et al, Osteoporos Int 1999 One woman in five will suffer from another vertebral fracture within a year Lindsay et al., JAMA, 2001

23 2-23 High Rate of Repeat Fractures % of Patients Fracturing Again within 1 Year Multiple 20% of women with new vert fx will re-fracture within one year Number of Spine Fractures at Start of Year Lindsay, 2000

24 Effect of Prior Vertebral Fracture on Risk of Subsequent Vertebral Fracture 2-24 Incidence of New Vertebral Fracture (%) RR=5.1 (3.1, 8.4) RR=2.6 (1.4, 4.9) RR=7.3 (4.4, 12.3) First Year of Study 2725 postmenopausal women randomised to placebo No. of Vertebral Fractures at Baseline Adapted from Lindsay R et al., JAMA 2001, 285:320

25 2-25 Vertebral Fractures in Summary Are the most common osteoporotic fractures Are associated with excess mortality Are associated with significant morbidity, even if they do not come to clinical attention Increase the risk of subsequent vertebral fracture(s) by 5 fold and of other fragility fractures (including hip) by 2 fold

26 2-26 Hip Fracture Impact on Life Quality 61 % of hip fractures occur at home 100 % hospitalized 82 % referred to rehabilitation clinic One year after hospitalization: 65 % live at home 17 % deceased 18 % need nursing Schürch M. et al, J. Bone Miner Res 1996; 12:

27 COST OF OSTEOPOROSIS 2-27

28 2-28 Some Costs of Osteoporosis in Europe In Europe the total direct costs of osteoporotic fractures are over 31 billion and are expected to increase to more that 76 billion in Kanis JA & Johnell O. - Osteoporos Int 2005 (in press) In France osteoporotic hip fractures are estimated to cost about 1 billion every year* In Spain the total direct hospital cost of osteoporotic fractures in 1995 was approximately 222 million* In England & Wales the total direct hospital cost of osteoporotic fractures in 1999 was approximately 847 million* *Osteoporosis in the European Community: A Call to Action. IOF Nov, 2001

29 Osteoporosis Results in More Disability & Direct Hospital Cost Than Many Other Diseases % of vertebral fractures are hospitalised and 2% require long-term nursing care Ross et al., Am Journal of Medicine 1997, 103(2A):30S 42S Annual cost of acute hospitalisation in Switzerland in 1992: 600 million Swiss francs (US$350 million) Lippuner et al., Osteoporosis Int 1997, 7: Number of bed days (men & women) 891,000 for COPD 701,000 for osteoporosis 533,000 for stroke 328,000 for myocardial infarction 201,000 for breast cancer Osteoporosis # 1 when looking at women only

30 2-30 UNDER-DIAGNOSIS OF VERTEBRAL FRACTURES: WHAT IS THE SIZE OF THE PROBLEM? Look for it!!

31 2-31 Unrecognized Vertebral Fractures On X-Ray women age 60 and older, hospitalized for various reasons Chest x-rays reviewed for fracture Number of Subjects % 40 23% 17% 20 7% 0 Fracture Present Mentioned in Report Mentioned in Summary Osteoporosis in Med Record Treatment for Osteoporosis Gehlbach SH et al, Osteoporos Int 2000;11:

32 2-32 High Prevalence of Vertebral Deformities 80 Prevalence of Deformities* (%) Melton, Age (yrs) 25% of women over age 50 have Vertebral Deformities

33 2-33 A Large Prospective Study Demonstrates Under- Diagnosis of Vertebral Fractures is a Worldwide Problem Vertebral fractures were markedly under-diagnosed in radiology reports in a multicenter, multinational study population of osteoporotic women (n=2451) in which 789 (32%) women had 1 vertebral fracture at baseline. Adjudicated discrepancies (n=350) between local and central readings due to undetected vertebral fracture (68%) or equivocal terminology in the local radiology report (32%) yielded a false-negative rate of 34%. Under-diagnosis of vertebral fractures was observed in all geographic regions (false-negative rates: North America 45.2%, Latin America 46.5%, Europe/South Africa/Australia 29.5%). The false-positive rate was 5% globally. Under-diagnosis of vertebral fracture is a worldwide problem attributable in part to a lack of radiographic detection or use of ambiguous terminology in the radiology report, or both. Delmas et al., J Bone Miner Res 2005, in press.

34 Background 2-34 Worldwide, a substantial percentage of vertebral fractures are not diagnosed by radiologists or clinicians It is likely that this contributes to unnecessary pain and suffering and to the under treatment of osteoporosis Identification of patients with a vertebral fracture is important because the presence of prevalent fracture greatly increases the risk of future fracture Recent widespread approval of effective treatments for patients with osteoporotic vertebral fractures

35 2-35 Problem: Vertebral Fracture Assessment by Radiologists Vertebral Fractures are: Not being identified Not being reported Not being acted upon

36 2-36 Are Physicians Treating Osteoporosis after Hip Fracture Center I II III IV n DXA 12% 12% 13% 24% Ca-Suppl. 27% 1% 3% 25% Estrogens 10% 6% 0% 14% Alendronate 8% 2% 4% 10% Calcitonin 11% 0% 0% 14% Raloxifene 0.1% 0% 1% 6% Total Treatment 29.1% 8% 5% 37% Harrington J. et al, Arthritis & Rheum. 2002; 47:651

37 2-37 Treatment of Osteoporosis Are Physicians Missing an Opportunity? 1162 women with a distal radial fracture, > 55yrs (60% < 74yrs) 2.8% had a bone-density scan (in 80% Osteoporosis found) 22.9% were treated with at least one medication (estrogen, bisphosphonates, calcitonin) 76% received neither a bone-density scan nor medical treatment of osteoporosis Freedman K. et al, J. Bone and Joint Surg 2000; 82-A:

38 2-38 When to Consider X-Ray Exam Clinical suspicion of vertebral fracture Pain Kyphosis Loss of height