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/m
2
)
 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
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400
600
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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 efficacy
28,29,30

 Changes in level of BTM can be seen within 3-6
months after initiation of drug therapy
26,27
(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