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Keywords:

  • clinical aspects;
  • disease aetiology and pathogenesis;
  • epidemiology;
  • osteoporosis;
  • rehabilitation

Abstract

  1. Top of page
  2. Abstract
  3. EPIDEMIOLOGY
  4. AWARENESS
  5. CHALLENGES TO TREATMENT
  6. FACING THE CHALLENGE
  7. REFERENCES

The prevalence of osteoporosis and fractures is projected to increase rapidly in the Asia-Pacific region in coming decades. At the societal level, healthcare providers will face the challenges of paucity of information, lack of awareness among physicians, resource constraints, lack of organization, absence of policies of cost reimbursement, insufficient representation of the problem in curricula and lack of effective, inexpensive and convenient therapy. Poverty, illiteracy, lack of awareness and interest in future quality of life, and co-morbidities with seemingly greater importance, will all act as challenges at the level of individual patients. Lack of compliance is a function of lack of awareness and motivation, cost, complexity of administration, side-effects and absence of immediately perceivable benefit. The challenges may be overcome through systematic collection of data, formation or activation of national osteoporosis planning and coordinating groups, development of national guidelines, programs of education of healthcare providers, patients and the general public, adoption of a population-based prevention strategy, cost-effective opportunistic screening using clinical decision rules like the osteoporosis self-assessment tool for Asians, use of the fracture risk assessment tool for therapeutic decision-making, giving due emphasis to the problem in curricula and development of mechanisms for cost reimbursement. The Asia-Pacific League of Associations for Rheumatology may take a lead in stimulating, organizing and coordinating these activities.

Osteoporosis leads to more than 8.9 million fractures per year around the globe. The combined lifetime risk for hip, forearm and vertebral fractures coming to clinical attention is around 40%, almost equal to that for coronary heart disease.1 The socio-economic burden of fractures on healthcare resources is expected to increase rapidly in the 21st century with the projected global cost of hip fracture alone estimated at US$131 billion in the year 2050.2 With changing age structure of populations, urbanization and consequent physical inactivity, smoking and alcohol consumption, population growth, price hikes and depletion of nutritional resources, the incidence of osteoporosis and fragility fractures may increase in the Asia-Pacific in the coming decades. Age-adjusted hip fracture rates appear to have leveled off in the USA,3 the UK4 and Sweden,5 but are increasing in Asia.6,7 By the year 2050, more than 50% of the global burden of osteoporotic hip fractures are projected to occur in Asia.8 Because of its morbid consequences, prevention of osteoporosis and resulting fractures is considered essential to the maintenance of health, quality of life and independence in the elderly population. The primary needs for effective prevention include a good body of knowledge about disease burden and awareness in the community and among physicians.

EPIDEMIOLOGY

  1. Top of page
  2. Abstract
  3. EPIDEMIOLOGY
  4. AWARENESS
  5. CHALLENGES TO TREATMENT
  6. FACING THE CHALLENGE
  7. REFERENCES

In the absence of a disease surveillance system, data on the prevalence of osteoporosis are bound to be scanty in the majority of the communities of the Asia-Pacific region.

In Australia, about 11% of men and 27% of women aged 60 or more years were found to have osteoporosis, and another 42% of men and 51% of women are osteopenic.9 In a study of subjects above 60 years of age in New South Wales, mean bone mineral density (BMD) of femoral neck of subjects with and without fracture was 0.72 and 0.79 g/cm2, respectively. In cases of lumbar spine, the corresponding values were 0.92 and 1.03 g/cm2, respectively.10 The latter values represented 6- and 9-fold risks of having a fracture compared to those with lumbar spine BMD of ≥ 1.3 g/cm2.11 In a study in Thailand, women at the age of 75 years had lost 21.4%, 18.5%, 6.5% and 13.7% of bone mass compared to peak values.12 Yong et al. reported a lower BMD in Korean women compared to that in Caucasians.13

In Thai women aged 75 years, vertebral fracture prevalence was 17.6%.12 In Hong Kong, the hip fracture rates for women and men aged 50 years and above were 2645 and 1621, respectively, per 100,000 in the year 1991.14 The incidence of hip fracture had increased by approximately two-fold between 1966 and 1985.6 The average risk of a Chinese woman for developing at least one osteoporotic fracture in her lifetime was 30%.15 In Japan, the age-adjusted incidence rate of proximal femoral fracture was 108 per 100,000 person-years in women and 54 in men, and that of distal forearm fracture was 149 in women and 59 in men. The corresponding rates in a Singaporean series were 42, 73, 59 and 73, respectively. The rates were much lower than corresponding rates in western populations.16

Death is relatively common in the months immediately after a hip fracture.17 Hip fracture survivors had an increased risk of dependence, with 50% requiring help with daily living activities and 15–25% entering long-term care.18 In Australia, the average cost of fractures treated in hospitals was US$7000 and that of fractures treated in outpatient clinics was US$300. The total direct cost attributable to all osteoporotic fractures was estimated at $700 million in 1994.19 In a more recent analysis, the cost of osteoporosis was estimated at about $7 billion annually taking into account all types of fractures and all types of direct and indirect costs.20 The cost of a hip fracture in Hong Kong was estimated at US$10,820 in the first year and that of a Colles’ fracture at US$600.21 The total cost of management of all acute hip fractures amounted to HK$270 million in the year 2000.22

Old age, younger age at menopause, lower BMI, family history of fracture, physical inactivity, smoking, low dietary calcium intake, heavy alcohol consumption and glucocorticoid use are recognized risk factors for osteoporosis.23 In a prospective study, dietary calcium intake in childhood was positively related to BMD in young women.24 In a multicentre study in Iran the following factors were found to predict an increased risk of osteoporosis: lower education, duration of menopause greater than five years, menarche after 14 years, menopause before 45 years, parity more than three, bone and joint disorders and steroid therapy. Pure vegetarianism and red meat consumption more than four times per week were found to be risk factors in Indian and Iranian subjects, respectively. Regular exercise, hormone replacement therapy (HRT) and calcium supplementation were identified as protective factors. Regular consumption of soya, almond, fish, fruits and milk-tea four cups per day or more appeared to be significant protective factors in India. Regular consumption of cheese, milk, chicken, eggs, fruits, tea seven cups or more per day were found to be significant protective factors in Iran.25 In a Thai rural study, average daily calcium intake among men and women were 378.6 and 265.6 mg, respectively. Sixty-seven percent of men and 87% of women had less dietary calcium intake than half of the recommended level (< 400 mg/day) whereas only 6% and 3% had an intake more than 800 mg/day.26 In a study among school and college girls in Korea, daily mean calcium intake was 461, 719, 768 and 867 mg at 12, 13, 14 and 15 years of age, respectively. Calcium intake, physical activity and menstrual status were found to affect peak bone mass in this study population.27 In a study of risk factors for fracture in New South Wales, low BMD at femoral neck, body sway and quadriceps strength were found to be the best predictors of fracture risk.10

AWARENESS

  1. Top of page
  2. Abstract
  3. EPIDEMIOLOGY
  4. AWARENESS
  5. CHALLENGES TO TREATMENT
  6. FACING THE CHALLENGE
  7. REFERENCES

The epidemic of osteoporosis is silent. The problem remains under-diagnosed and under-treated. It is agreed that individuals with low BMD, particularly those with history of a fracture (with osteoporosis or osteopenia), should be considered for treatment. In a study in the USA, among hospitalized women aged 60 or older with vertebral fractures at spine radiographs, the fracture was mentioned in the medical records or discharge summary of only 17%.28 Among women aged 55 years or more with wrist fractures, 23% were started on some form of osteoporosis-specific therapy, and less than 3% had a BMD scan.29 Out of 502 hospitalized hip-fracture patients, 14% had BMD scans, 13% received calcium and/or vitamin D, and 18% received HRT, calcitonin or bisphosphonates.30 In two other studies, 5% of patients with recent hip fractures left the hospital with a new medication prescribed for reducing future risk of fractures.31,32 In a recent survey of more than 88,000 women attending 927 primary care physicians in Australia, less than 20% of those with postmenopausal fracture were on some antiresorptive therapy.33

The awareness situation is likely to be worse in resource-constrained parts of the Asia-Pacific with higher rates of illiteracy and less organized curricula. In a survey of osteoporosis awareness among physicians practicing in Hong Kong, 41% responded to the invitation to participate, 76% reported that they were treating osteoporosis, 53% used dual energy X-ray absorptiometry (DEXA) for its diagnosis, 35% used peripheral machines as the only diagnostic tools, 33% were aware of the existence of a set of national guidelines. Out of 204 respondents, 82% recognized reduction of fracture risk, 66% improvement of the quality of life and 50% recognized increasing BMD as a treatment goal. Sixty per cent of the respondents referred to the cost of evaluation and treatment as the major concern in osteoporosis management. The authors concluded that the physicians were not proactive in screening for risk factors for osteoporosis and were not identifying osteoporosis patients for treatment, osteoporosis was under-diagnosed and under-treated, cost was an important impediment and efforts to increase physicians’ knowledge and awareness needed to be expanded in Hong Kong.34

CHALLENGES TO TREATMENT

  1. Top of page
  2. Abstract
  3. EPIDEMIOLOGY
  4. AWARENESS
  5. CHALLENGES TO TREATMENT
  6. FACING THE CHALLENGE
  7. REFERENCES

Patient compliance is a major global challenge in the management of chronic disorders including osteoporosis. With HRT, 10% of the women in the USA continued treatment for more than 1 year.35 Cramer et al. showed that compliance increased with the use of weekly formulations of bisphosphonates. But the persistence rates were low even with the weekly formulations.36 In an observational real-life study, adherence of Asian women to raloxifene therapy was compared with that to oral bisphosphonates. Investigators from Hong Kong, Malaysia, Pakistan, Philippines, Singapore and Taiwan participated in the study; 707 patients on raloxifene and 277 on oral bisphosphonates were followed up. It was found that 71.4% and 59.2%, respectively, expressed their satisfaction and 7.4% and 19.1%, respectively, expressed their dissatisfaction with the formulation they were taking. Fifty percent and 37.5% and of the study subjects completed the follow-up in raloxifene and bisphosphonate groups, respectively. In the raloxifene group, the main reason for discontinuation was the cost (25%) followed by side-effects (6%). In the bisphosphonates group, it was inconvenience of dosing (19%) followed by cost (11%) and side-effects (5%). The factors reported to affect convenience were difficulty in remembering (18.4%), complexity of intake (36.9%), lack of liberty in taking any time of day (24.3%) and inability to eat and drink with the drug (23.3%).35 It appears that compliance is a function of cost, simplicity of dosing, efficacy, toxicity and possibly patient motivation. The findings of this study gives us an insight into the fact that challenges to treatment of osteoporosis including the challenge of compliance may be patient-independent and patient-related.

Challenges at the community level

Challenges at the societal level starts with lack of information. A WHO task force comments, ‘National strategies for assessment and diagnosis of osteoporosis will depend on many considerations, but the size of the problem expressed both in absolute terms and relative to other health care needs is of greatest importance.’37 Mean BMD of the healthy adult population, prevalence of osteoporosis, bone-related nutritional state or nutrient intake, other community-specific modifiable risk factors for osteoporosis and falls, prevalence of fragility fractures and functional, economic and quality of life impact of osteoporosis are not studied in the majority of the Asia-Pacific communities. It may be bluntly stated that the importance of this malady is not objectively ascertained in this part of the globe. The governments and the policy makers may question the position of osteoporosis in the list of national priorities on the grounds of lack of substantial volume of data.

Screening for osteoporosis is considered an important step for prevention of fractures, particularly since it remains silent till the first fracture. Most of the world's ageing population lives in the developing countries where DEXA is either not available or its cost is prohibitive.34 To justify a screening program, a disease must have been demonstrated to be an important health problem. The importance of osteoporosis is not yet demonstrated in the Asia-Pacific. From data on prevalence of fractures in Japan and Singapore compared to those in Western communities,16 it may appear rather to be less important in some parts of Asia. Because of lack of adequate testimony to its importance, resource constraints, the cost of screening tools, possible large numbers needed to treat (NNT) of the interventional strategies and high cost of the antiresorptive drugs, population screening, screening at menopause and even screening in later life may not be feasible strategies in the majority of communities. Opportunistic screening of patients presenting with the first low-trauma fracture, family history of fractures, premature menopause or multiple other risk factors for osteoporosis and falls may remain the only realistic approach to case finding in the Asia-Pacific. The success of the approach of opportunistic screening largely depends on awareness of physicians and the maintenance of a high index of suspicion. Lack of awareness among physicians has been well-highlighted in the above-mentioned reports from Australia33 and Hong Kong.34 The scenario may be even worse in other Asia-Pacific communities.

With the fact that a consensus definition of osteoporosis was accepted only before 15 years38 and operational definitions were established only in 1994,1,39 even in Western countries osteoporosis is unlikely to be given a high priority. Resources constraint is another major challenge that affects treatment of osteoporosis in Asia-Pacific communities. The majority of the countries in this region have low per capita GDP. They are moreover plagued with other health priorities. They include millennium-spanning endemic infectious diseases, like tuberculosis, malaria, visceral leishmaniasis, etc., combined with emerging epidemics of symptomatic and potentially lethal non-communicable diseases, like coronary heart disease, diabetes and cancer. Against this background of astringent resources and pressing health needs, osteoporosis often ranks low in the priority list of governmental bodies in the absence of demonstrated evidence of its importance.

Bone and mineral metabolism and osteoporosis in general are under-represented in under- and postgraduate curricula in most of the Asia-Pacific communities. It is reflected in the low level of awareness about various aspects of osteoporosis among physicians in Asia.

Asia-Pacific countries often lack organized systems of evidence-based fiscal priority-setting, disease surveillance, health care delivery and reorganization of curricula. It affects the precise estimation of community burden of diseases along with their functional, quality of life and economic impact, proper allocation of budget, cost-reimbursement, undergraduate and postgraduate education of physicians and measures for increasing community awareness. Absence of social support systems stems from both resource constraints and lack of organization.

The paucity of effective, convenient and inexpensive therapy compromises osteoporosis treatment in Western and more so in Asia-Pacific communities. Undoubtedly, bisphosphonates are one of the most effective antiresorptive drugs. Besides the complexity of the mode of intake, their cost is quite prohibitive for the majority of the Asia-Pacific communities. There are efforts at developing formulations with simpler methods of intake, e.g. weekly formulation, monthly formulations, e.g. ibandronate and annual intravenous formulation (zoledronic acid) that, besides increasing the dosing interval, bypasses the gastrointestinal tract. But the simpler the dosage regimen, the more costly is the formulation.

Patient-related challenges

Poverty is the most important patient-related challenge to the treatment of osteoporosis in Asia. In the study of Kung et al. cost was considered as the greatest barrier to management of osteoporosis.34 In the series of Pasion et al. it was the leading cause in the raloxifene group and the second cause of discontinuation in the bisphosphonate group.40 The unusually low daily calcium intake in the Thai community26 might have stemmed from poverty and inability to purchase dairy products. The majority of the elderly people have comorbidies like hypertension, diabetes, vascular atherosclerosis. These conditions are either symptomatic or the level of community awareness about their consequences is already high. People who fall ill often face a dire choice: either to suffer death without treatment or to seek treatment and push their family into poverty.41 In these communities, households often sell their possessions to cover healthcare costs, particularly when chronic diseases require long-term costly treatment.42 Osteoporosis is silent. Fracture is not its inevitable consequence and a poor individual in a constrained Asian community is unlikely to survive long enough to have a high lifetime risk of fracture. A constrained individual is more likely to spend his biting resources on the symptomatic diseases and on diseases with more proximal lethal consequences rather than on osteoporosis unless he is properly educated and motivated.

Asia-Pacific countries often lack organized systems of evidence-based fiscal priority-setting, disease surveillance, health care delivery and reorganization of curricula. It affects precise estimation of community burden of diseases along with their functional, quality of life and economic impact, proper allocation of budget, cost-reimbursement, undergraduate and postgraduate education of physicians and measures for increasing community awareness. Absence of social support systems stems from both resource constraint and lack of organization.

In the Indonesian COPCORD study, approximately 90% of the respondents resorted to traditional healers, spending on which is sometimes wasteful.43

FACING THE CHALLENGE

  1. Top of page
  2. Abstract
  3. EPIDEMIOLOGY
  4. AWARENESS
  5. CHALLENGES TO TREATMENT
  6. FACING THE CHALLENGE
  7. REFERENCES

Physicians have to take the key role in facing the above-mentioned challenges. Studies should be conducted to find out the mean BMD of the healthy adult population, prevalence of osteoporosis, bone-related nutritional state and nutrient intake, other community-specific modifiable risk factors for osteoporosis and falls, prevalence of fragility fractures and functional, economic and quality of life impact of osteoporosis. National osteoporosis planning and coordinating groups may be formed in countries in which they still do not exist. Such groups should include physicians, rheumatologists, orthopedicians, gynecologists, endocrinologists, nurses, health education specialists, health economists, medical sociologists, representatives of patient support networks and mass media specialists. A checklist of issues that need to be considered by such groups is provided in the 2003 Report of the WHO Scientific Group.37 The report emphasizes the need for development of national guidelines. The national osteoporosis planning and coordinating groups may adapt the available international guidelines,44–46 keeping regional characteristics of the population in consideration.

Steps may be taken to improve the awareness situation in these countries. The education of health professionals may be targeted to specialists, primary care physicians, nurses, dietitians, social workers and officials of the ministries of health. The methods used in continuing education may include lectures, training courses, scientific journals, video cassettes and internet.37 In under- and postgraduate curricula, due emphasis should be given to bone and mineral metabolism, pathogenesis, prevention and treatment of osteoporosis. Physicians should be re-educated to heighten their index of suspicion in patients with multiple risk factors so that the scope of opportunistic screening is not underutilized. Patient education may greatly contribute to reducing non-compliance.37 Patients should be educated on the natural course and consequences of the disease, lifestyle factors, scope and limitations of the available therapeutic options and on methods for prevention of falls.

It may be speculated that education of the general public through the press, radio and television may be one of the most cost-effective strategies for prevention of osteoporosis in the community. Politicians and health administrators also need an adequate knowledge of the disease. School teachers can help young adults to maximize their peak bone mass.37 Considering the cost and unavailability of DEXA and antiresorptive drugs, a population-based prevention strategy may turn out to be the only practicable choice in majority of the Asia-Pacific communities. Obvious interventions include raising the level of exercise, stopping smoking and increasing dietary calcium intake.47–49 In the MEDOS study in southern Europe, increase in the intake of calcium in the population was associated with a decreased risk of hip fracture.50 A rise in BMD by 10% through community interventions may be expected to decrease fracture rates by 20%.46 This preventive strategy may be more cost-effective in communities in which the burden of risk factors is high. The very low calcium intake in the Thai community is an example of such a high burden.26

The osteoporosis self-assessment tool for Asians (OSTA) is a simple questionnaire comprising clinical items. The OSTA score was calculated for each woman using her age and weight, according to the formula: 0.2 (weight-age). Women with OSTA scores < or = –1 and > –1 were classified as ‘high risk’ and ‘low risk,’ respectively.51 Its validity and reliability have been documented in Chinese52 and Singaporean women,53 in Philipinos,54 and in Asian men.55 Its user-friendly nature permitted its effective use in community pharmacy-based osteoporosis risk assessment services in Thailand.56 In a study among women in Shichuan province of China, its concurrence with lumbar spine BMD was low.57 In a study in a Thai population, the OSTA score had high sensitivity but low specificity and low positive predictive value in the identification of osteoporotic women. It was suggested that its use in the general population could result in a high false-positive rate and incur significant cost to the community.58 In another study in Thailand, both sensitivity and specificity of OSTA was enhanced by a change in the cut-off point.59 Pending further improvement of the instrument, continued use of OSTA as a clinical decision rules (CDR) would help target high-risk women for BMD measurements, thereby avoiding the cost of measuring women at low risk. Fracture risk assessment tool (FRAX) was developed based on the use of clinical risk factors with or without bone mineral density testing. The clinical risk factors comprised body mass index (BMI), prior history of fracture, parental history of hip fracture, use of oral glucocorticoids, rheumatoid arthritis and other secondary causes of osteoporosis, current smoking, and alcohol intake.60 A model appropriate for the local population has been developed in Japan.61 The FRAX provides an opportunity for therapeutic decision-making in communities where BMD measurement facilities are not available or their their use is limited by cost.

Mechanisms for reimbursement of the cost of bone density measurement and drug treatment of osteoporosis should be developed in countries where they do not exist. The national osteoporosis planning and coordinating groups may contribute to development of such mechanisms through discussions and negotiation with policy makers, insurance companies and corporate employers. The pharmaceutical industry and governments may be persuaded to adopt different pricing and taxation policies for antiresorptive drugs in under-privileged communities.

It may be concluded that the burden of osteoporosis and fracture is increasing in the resource-constrained Asia-Pacific communities. The prevention and treatment of osteoporosis is fraught with multiple challenges that include lack of basic data, poverty and resource constraints, low levels of education, lack of awareness among physicians and in the community, other priority medical problems, lack of organized systems of surveillance, feed-back and evidence-based priority setting, absence of mechanisms for cost reimbursement, under-representation of the problem in curricula, taxation and pricing policies. Facing this colossal challenge will require a concerted effort by health professionals, policy makers, community leaders, employers, the pharmaceutical industry, media and patient representative groups. The Asia-Pacific League of Associations for Rheumatology (APLAR) may urge its affiliate national societies through osteoporosis special interest groups (SIG) to play a key role in coordinating such efforts.

REFERENCES

  1. Top of page
  2. Abstract
  3. EPIDEMIOLOGY
  4. AWARENESS
  5. CHALLENGES TO TREATMENT
  6. FACING THE CHALLENGE
  7. REFERENCES
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