2010 Guidelines 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis...

2010 Guidelines2010 Guidelines

2010 Clinical Practice2010 Clinical Practice Guidelines for the Guidelines for the Diagnosis and Management Diagnosis and Management of Osteoporosis in Canadaof Osteoporosis in Canada

Papaioannou A, et al. CMAJ 2010 Oct 12. [Epub ahead of print].


Fragility FracturesFragility Fracturesand Care Gapsand Care Gaps

2010 Guidelines

Section TwoSection Two


Fragility Fracture: DefinitionFragility Fracture: Definition

• A fracture occurring spontaneously or following minor trauma such as a fall from standing height or less1,2

– Excluding craniofacial, hand, ankle and foot fractures

1. Kanis JA, et al. Osteoporos Int 2001; 12(5):417-427.2. Bessette L, et al. Osteoporos Int 2008; 19:79-86.


The Majority of Fractures in Canadian The Majority of Fractures in Canadian Women Women >> Age 50 Are Fragility Fractures Age 50 Are Fragility Fractures

Bessette L, et al. Osteoporos Int 2008; 19:79-86.

% o

f al

l fra

ctur

es t

hat

are

frag

ility

fra

ctur

es

75.7%

91.8%Overall: 81%

95%

90%

85%

80%

75%

70%

65%

60%50-59 60-69 70-79 80+

Age groups


Consequences of FractureConsequences of Fracture

• Increased risk of– Hospitalization/institutionalization1,2

– Death3-5

– Subsequent fracture6-8

• Decreased quality of life9-12

• Economic burden on healthcare system2

1. Papaioannou A, et al. Osteoporos Int 2001; 12(10):870-874.2. Wiktorowicz ME, et al. Osteoporos Int 2001; 12(4):271-278.3. Ioannidis G, et al. CMAJ 2009; 181(5):265-271.4. Papaioannou A, et al. J SOGC 2000; 22(8):591-597.5. Tosteson AN, et al. Osteoporos Int 2007; 18(11):1463-1472.6. Papaioannou A, et al. J SOGC 2000; 22(8):591-597.

7. Colon-Emeric C, et al. Osteoporos Int 2003; 14:879-893.8. Lindsay R, et al. JAMA 2001; 285:320-323.

9. Sawka AM, et al. Osteoporos Int 2005; 16:1836-1840.10. Cranney A, et al. J Rheumatol 2005; 32(12):2393-2399.

11. Pasco JA, et al. Osteoporos Int 2005; 16(12):2046-2052.12. Papaioannou A, et al. Osteoporos Int 2009; 20(5):703-715.


Impact on Function and Quality of LifeImpact on Function and Quality of Life

• Loss of confidence and fear of falling have been reported with all types of fractures

• < 40% of those who experience a hip fracture return to their prior walking abilities1,2

• Clinical fractures negatively affect self-care and mobility, and are associated with chronic pain3

1. Cranney A, et al. J Rheumatol 2005; 32(12):2393-2399.2. Pasco JA, et al. Osteoporos Int 2005; 16(12):2046-2052.

3. Papaioannou A, et al. Osteoporos Int 2009; 20(5):703-715.


Undertreatment of Osteoporosis Post Undertreatment of Osteoporosis Post Fracture in WomenFracture in Women11

5.5%

15.4%

79.0%

No diagnosis or treatment forosteoporosisDiagnosis of osteoporosis only

Prescribed treatment forosteoporosis

1. Bessette L, et al. Osteoporos Int 2008; 19:79-86.2. Papaioannou A, et al. Osteoporos Int 2008; 19(4):581-587.

3. Giangregorio L, Osteoporos Int 2009; 20(9):1471-8. 4. Austin PC, et al. CMAJ 2008; 179(9):901-908.

This care gap is even wider in men and those who reside in long-term care2,3

A fracture is to osteoporosis what a heart attack is to cardiovascular disease. BUT... The treatment gap is far wider post fracture than post MI.1,4


Looking Beyond BMDLooking Beyond BMD

• Currently, low BMD is the primary trigger for initiation of therapy1-5 . . . HOWEVER,

• Most fragility fractures occur in those with a BMD in the non-osteoporotic range (T-score higher than -2.5)6

There is a missed opportunity to prevent future fractures due to over-reliance on BMD.6,7

1. Bessette L, et al. Osteoporos Int 2008; 19:79-86.2. Papaioannou A, et al. BMC Musculoskelet Disord 2004; 5:11.3. Elliot-Gibson V, et al. Osteoporos Int 2004; 15:767-778.4. Papaioannou A, et al. Osteoporos Int 2008; 19(4):581-587.

5. Cranney A, et al. Osteoporos Int 2009; 20(9):1621-1625.6. Cranney A, et al. CMAJ 2007; 177(6):575-580.

7. Langsetmo L, et al. J Bone Miner Res 2009; 24(9):1515-1522.


Back-up MaterialBack-up Material

Additional slides that can be accessedby hyperlinks on core slides

Section Two Section Two – Fragility Fractures and Care Gaps– Fragility Fractures and Care Gaps


Fracture is a Predictor of Future FracturesFracture is a Predictor of Future Fractures

• The risk of experiencing another fracture in the year following a hip fracture*: 5% – 10%1,2

• The risk of experiencing another vertebral fracture in the year following a vertebral fracture†: 20%3

• Prevalent vertebral fractures also predict hip fracture*4,5

• 40% of Canadians who experience a fracture have a history of prior fracture6

1. Papaioannou A, et al. JOGC 2000; 22(8):591-597. 2. Colon-Emeric C, et al. Osteoporos Int 2003; 14:879-893.

3. Lindsay R, et al. JAMA 2001; 285:320-323.4. Ismail AA, et al. Osteoporos Int 2001; 12(2):85-90.

5. Melton LJ 3rd, et al. Osteoporos Int 1999; 10(3):214-21.

6. Hajcsar EE, et al. CMAJ 2000, 163:819-822. Return to main presentation

* in men and women † in postmenopausal women


One-year Mortality Risk after Hip FractureOne-year Mortality Risk after Hip Fracture

25%

39%

0%

10%

20%

30%

40%

50%

Overall Patients in long-term carefacilities

% m

ort

alit

y at

on

e ye

ar

1 2

1. Ioannidis G, et al. CMAJ 2009; 181(5):265-271.2. Papaioannou A, et al. J SOGC 2000; 22(8):591-597.


2.62 2.71

0

0.5

1

1.5

2

2.5

3

First year Second year

Adj

uste

d H

azar

d Ra

tio fo

r Dea

th

Increased Mortality Risk after Increased Mortality Risk after Vertebral FractureVertebral Fracture

12

Ioannidis G, et al. CMAJ 2009; 181(5):265-271.Return to main presentation


HUI3 Deficits Associated with FracturesHUI3 Deficits Associated with Fracturesin Women, by Fracture Typein Women, by Fracture Type

Return to main presentation Papaioannou A, et al. Osteoporos Int 2009; 20(5):703-14.

Multi (HUI2)

0

-0.05

-0.1

-0.15

-0.2

-0.25

Mobility(HUI2)

Pain(HUI2)

Self-care (HUI2)

Multi(HUI3)

Ambulation(HUI3)

Pain(HUI3)

OtherRibSpineHip


Increasing Costs AssociatedIncreasing Costs Associatedwith Hip Fracture ($CDN)with Hip Fracture ($CDN)

$650 million

$2.4 billion

0

0.5

1

1.5

2

2.5

3

1993 (estimated) 2041 (projected)

An

nu

al C

ost

s ($

Bil

lio

ns)

Return to main presentation Wiktorowicz ME, et al. Osteoporos Int 2001; 12(4):271-278.


Therapeutic Care Gap: Most Men Do Not Receive Therapeutic Care Gap: Most Men Do Not Receive Treatment for Osteoporosis after Fracture Treatment for Osteoporosis after Fracture

94.2% 94.0% 91.6% 92.6% 90.5%99.5%

0%

20%

40%

60%

80%

100%

Baseline Year 1 Year 2 Year 3 Year 4 Year 5

% o

f m

en

with

fra

gili

ty f

ract

ure

wh

o d

o n

ot

rece

ive

th

era

py

Return to main presentation Papaioannou A, et al. Osteoporos Int 2008; 19(4):581-587.


Post-fracture Care Gap:Post-fracture Care Gap:Comparison with Heart AttackComparison with Heart Attack

~15%

~80%

0

20

40

60

80

100

Anti-osteoporosis medication postfracture

Beta-blockers post heart attack

% o

f p

ati

en

ts b

ein

g t

rea

ted

1. Bessette L, et al. Osteoporos Int 2008; 19:79-86.2. Austin PC, et al. CMAJ 2008; 179(9):901-908.Return to main presentation


No. of fractures

No.

of f

ract

ures

0

100

200

300

400

500

Most Fragility Fractures in Postmenopausal Most Fragility Fractures in Postmenopausal Women Occur with Low Bone Mass ("Osteopenia")Women Occur with Low Bone Mass ("Osteopenia")

Return to main presentation Cranney A, et al. CMAJ 2007; 177(6):575-580.

> 0.0 0.0to -0.5

-0.5to -1.0

-1.0to -1.5

-1.5to -2.0

-2.0to -2.5

-2.5to -3.0

-3.0to -3.5

≤ -3.5 Normal Osteo-penia

Osteo-porosis

WHO categoryT-score

60

50

40

30

20

10

0

Fracture rate

Frac

ture

rate

, per

100

0 pe

rson

-yea

rs

There is a missed opportunity to prevent fractures due to over-reliance on BMD.

2010 Guidelines 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis...

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