Prevalence of osteoporosis in Middle East systemic literature review

Mohy Taha, MD AOCID Clinical Research Fellow Kantonsspital Aarau, Switzerland

10th ECOO 14-16 April 2011

A medical revolution
‡ 1958: Foundation of the ÄArbeitsgemeinschaft für Osteosynthese / AO³ (Association for the Study of Internal Fixation) in Biel/Switzerland by 13 visionary surgeons Revolution in trauma care and treatment of musculoskeletal disorders worldwide Principles of osteosynthesis: - established by those pioneers - further developed over the past 50 years - today: golden standard in modern trauma and orthopedic surgery

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AO Clinical Investigation & Documentation

Davos, headquarters

Dübendorf/Zürich office

Clinical Research

Step 1 Idea Define clinical question and specific aims

Step 2 Planning Study protocol Regulatory affairs

Step 3 Implementation Monitoring Follow-up

Step 4 Reporting Results Statistics

Step 5 Publication Submission Revision Acceptance

Good Clinical Practice (GCP) training

From Cairo to Clinical Research

Publications
Leihnhase I, Rozanski M, Harhausen D, Thurman JM, Schmidt OI, Hossini AM, Taha ME, Rittirsch D, Ward PA, Holers VM, Ertel W, Stahel PF. Inhibition of the alternative complement activation pathway in traumatic brain injury by a monoclonal anti-factor B antibody: a randomized placebo-controlled study in mice. J Neuroinflammation. 2007 May 2.

Leinhase I, Holers VM, thurman JM, Harhausen D, Schmidt Ol, Pietzcker M, Taha ME, Rittirsch D, Huber-Land M,Smith WR, Ward PA, Stahel PF. Reduced neuronal cell death after experimental brain injury in mice lacking a functional alternative pathway of complement activation. BMC Neurosci. 2006 Jul 14.

Leinhase I, Schmidt Ol, Thurman JM, Hossini AM, Rozanski M, Taha ME, Scheffler A, John T, Smith WR, Holers VM, Stahel PF Pharmacological complement inhibition at the C3 convertase level promotes neuronal survival, neuroprotective intracerebral gene expression, and neurological outcome after traumatic brain injury. Exp Neurol. 2006 Mar 16

Challenges in osteoporosis: increase in....
‡ ‡ ‡ ‡ ‡ The aging population Life expectancy in the developing countries Prevalence of osteoporosis Burden of osteoporotic fractures Missing data for the Middle East*

*Maalouf et al. J Musculoskelet Neuronal Interact 2007; 7(2):131-143

The aging population
In Europe, over 65: ‡ 12-17% in 2002 ‡ 20-25% by 2025 In developing countries, over 65: ‡ 5.5% ‡ Changes are expected

United Nations world population prospects: the 2002 revision

Change in life expectancy 1950 - 2045

United Nations World Population Prospects, 2008

75% of elders developing countries
2050 !

Towards Age-friendly primary health care; Active ageing series: WHO 2004

Are fragility fractures common?
Age = 50, lifetime risk > risk of breast, ovarian & uterine cancer > risk of prostate cancer Age > 50 ‡ 1:2 and 1:5 will suffer from a fracture in the remaining life time ‡ 55% have a low bone mass increased risk of fracture
Johnell et al. Osteoporosis Int., 2005; 16: S3-7

Burden of osteoporotic fractures
In Europe1

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¼ 31 billion/year ¼ 76 billion by 2050

In Middle East, Iran2 ‡ $ 8-16 million/year ‡ 2 million people at risk of fracture

1Kanis

2Larijani

and Johnell, Osteoporos Int. 2005; 16 Suppl 2:S3-7 B, 1st International Osteoporosis Seminar in Iran. Teheran, Iran; 2004

Orthopedic Surgeons?
‡ Fx often 1st indication for Osteoporosis1 ‡ 1st (only) to meet fracture patients1 ‡ 80% (2737/3422) don¶t measure the BMD after 1st fx2 ‡ 75% (2310/3422) lack appropriate knowledge about osteoporosis2

1 Bouxsein

2 Dreinhöfer

et al. J Am Acad Ortho Surg. 2004; 12:385-95 et al. Osteoporos Int 2005; 16:S44-S54

A systemic literature review
Objective: ‡ ‡ ‡ Identify Review Summarize literature on the prevalence of osteoporosis in the Middle East Identify literature on the incidence of fragility fractures

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Middle East?

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Bahrain Egypt Iran Iraq Jordan Kuwait Lebanon

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Libya Palestine Oman Saudi Arabia Syria Tunisia UAE

Materials & methods
Inclusion criteria:
‡ ‡ Research in the mentioned 14 countries Population > 18 years

Sources:
‡ ‡ ‡ ‡ Medline / EMBASE / Ovid Local osteoporosis societies WHO Non/locally published data

Keywords:
‡ ‡ ‡ Disease Location Epidemiology

Search criteria on 03.03.11
Disease:
(Osteoporosis OR Osteopenia OR Osteopenic OR Osteoporotic OR bmd OR bone mineral density) AND ‡

Location:
(³Middle East´ OR Bahrain OR Bahraini OR Egypt OR Egyptian OR Iran OR Iranian OR Iraq OR Iraqi OR Jordan OR Jordanian OR Kuwait OR Kuwaiti OR Libya OR Libyan OR Palestine OR Palestinian OR Oman OR Omani OR ³Saudi Arabia´ OR ³Saudi Arabian´ OR Syria OR Syrian OR Tunis OR Tunisian OR UAE OR ³Emirates´ OR Emirati) AND ‡

Epidemiology:
‡ (Incidence OR prevalence)

Sources in Cairo
‡ ‡ ‡ ‡ ‡ Egyptian Osteoporosis Prevention Society Academy of Scientific Research & Technology Central library Cairo University Central library Ain Shams University WHO-EMRO

Literature treasure
‡ ‡ ‡ ‡ ‡ ‡ 61/257 articles (Pubmed) 13/195 articles (Embase) 6 5 85 15 locally published WHO (EMRO) total articles articles (EGY)

WHO criteria for diagnosis of osteoporosis
Comparison of a patient¶s BMD with the mean for normal young adult population
T-score Normal Osteopenia Osteoporosis Severe osteoporosis -1 and above -1 to -2.5 -2.5 and below -2.5 and below with fragility fracture

Derived from European & North American postmenopausal women

Kanis et al. J Bone Miner Res 1994 ; 9:1137-41

Ancient Egyptians (2687-2191 BC)
‡ ‡ ‡ ‡ 74 Skeletons 20-60 years DXA Radius, 4th Lumbar, Femur
Osteopenia % Males (43) 18.6 Osteoporosis % 9.3

Females (31)

22.5

16.1

Zaki et al. Int. J. Osteoarchaeol. 2009 19: 78-89

Osteoporosis in Women
Authors
Rashed et al (2011) Hussein et al (2009) Moussa et al (2003) Taha et al (2003) Al-Bahnasy (2003) Nahia (2003) Rashed et al (2000) El-Husseiny et al (2000)

# patients 18000 71 2886 1000 5587 1200 1243 1190

Age (mean) Method 60-80 (66.1) DXA 22-48 (34) 35-89 (--) U-Sono DXA

Osteopenia 53.7 16.9 55.7 17.6 9.5

Osteoporosis 30.9 1.4 12.5 47.4

Reference population

-INT EGY INT INT INT EGY(INT) --

18-89 (47.3) U-Sono 40-65 (--) 40-66 (--) 20-84 (--) 31177 DXA CT DXA

12.9 osteopenia -26.9 10 % 34.7(43.7) 11.2(25.4)

20-89 (54.1) DXA

osteoporosis -22.3 18.6 %

Osteoporosis in Postmenopausal women

Authors
Rashed et al (2011) Moussa et al (2003)

# patients 18000

Age (mean) Method 60-80 (66.1) DXA

Osteopenia 53.7

Osteoporosis 30.9

Reference --

2886

35-89

DXA

55.7

12.5

EGY

osteopenia 53.9 % 20886 osteoporosis 28.4 %

Osteoporosis in Men

Authors
Al-Gendi et al (2007) Salem et al (2000)

# patients 100

Age (mean) Method 30-65 (44.7) U-Sono

Osteopenia 26

Osteoporosis 11

Reference EGY

55

20-89 (54.9) DXA

--

41.8

--

osteopenia 26 % 155 osteoporosis 21.9 %

Can we compare Egypt to US/Europe?

Rashed et al. The Bone Mineral Density of the Egyptian Reference Women, 2002

Can we compare Middle East countries?

Rashed et al. The Bone Mineral Density of the Egyptian Reference Women, 2002

Challenges
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Diff. methods Diff. locations & values Osteoporotic according to which location? Missing absolute numbers Upper & lower limits of age groups Reference population Osteopenic patients Values of the control group in 2ry osteoporosis Retrospective design Repetition of results

Benefits
‡ ‡ ‡ ‡ Quantify the size of the problem in the Middle East Recognize research deficits Identify research opportunities in the region Experience in literature reviews

Timetable
February-March 2011:
‡ ‡ Searching Collection of full articles

April 2011:
‡ ‡ Reading Data extraction

May-June 2011:
‡ ‡ ‡ Analysis Summary Preparing manuscript

Exercise helps fighting osteoporosis!

Questions?
B. Calman, 83 years old yoga instructor, Australia, THE SUN NEWS 05/2009