NGUYEN THI NGOC LAN- TAO THI MINH THUY

ASSESSING THE RISK FACTORS FOR OSTEOPOROSIS AND PREDICTING FRACTURE RISK FOLLOWING FRAX MODEL IN WOMEN AGED FROM 50 YEARS AND ABOVE IN THE NORTHERN PART OF VIETNAM NGUYEN THI NGOC LAN- TAO THI MINH THUY Ha Noi Medical University 1

REASON FOR STUDY Osteoporosis and consequence + Decline of life quality + Increasing mobility: 20% after hip fracture + Economy damage: 17 billion USD (USA: 2005) 2

REASON FOR STUDY Prognostic factors of fracture + Age + Bone mineral density (BMD) + Other factors FRAX: detecting risk of fracture Vietnam: few research 3

OBJECTS 1/ To investigate risk factors for osteoporosis in women aged from 50 and higher in Bach Mai hospital 2012 2/ To predict risk of fracture by using FRAX algorithm in subjects above 4

OVERVIEW 1/ Giảm Definition mật độ xương of osteoporosis (WHO Tổn 1993) thương vi cấu trúc xương Britle bone Age BMD Đốt sống World Health Organization (WHO), 1993. Increase risk of fracture Ngoài đốt sống

OVERVIEW 2/ Bone strength: major factors Bone strength Age Bone quality Characteristic of bone mineral Mư c đô khoa ng ho a xương Micrỏarchitecture Đô da y va ca c lô hô ng ơ vo xương Sư liên kê t va đô da y cu a be xương Slide 1.2.1.5

OVERVIEW 3/ Bone mineral density ( T_Score) Lumbar T_score Femoral neck T_score

OVERVIEW 4/ Diagnosis osteoporosis Interpreting T-scores (WHO) Correlates With Lifetime Fracture Risk for Caucasian Women Osteoporosis Low Bone Mass (Osteopenia) Normal Bone Mass -4.0-3.5-3.0-2.5-2.0-1.5-1.0-0.5 0 +0.5 +1.0

OVERVIEW 5/ Risk factors Ten Year Fracture Probability (%) Bone Density & Age vs. Fracture Risk 50 40 30 20 10 Age 80 70 60 50 0 1.0 0.5 0.0-0.5-1.0-1.5-2.0-2.5-3.0-3.5-4.0 Femoral Neck T-score Probability of first fracture of hip, distal forearm, proximal humerus, and symptomatic vertebral fracture in women of Malmö, Sweden. 9 Adapted from Kanis JA

OVERVIEW 5/ Risk factors Prognostic factor of fracture age and BMD are not enough >50% of fractural patients have normal BMD female Male BMD T-scores:normal 55% BMD T-scores: normal 74% fracture 45% BMD T-scores -2.5 fracture 26% BMD T-scores -2.5 (Nguyen ND et al., JCEM 2007))

ASSESING OSTEOPOROSIS RISK FACTORS ACORRDING TO IOF 1. Have either of your parents been diagnosed with osteoporosis or broken a bone after a minor fall? 2. Have you ever broken a bone after a minor fall? 3. Have you ever taken corticosteroid for more than 3 consecutive months? 4. Have you lost more than 3 cm in height? 5. Do you regularly drink alcohol? 6. Do you currently, or have you ever, smoked >20 cigarettes per day? 7. Do you often have diarrhea For female 8. Were your ovaries removed before age 45 9. Have your periods ever stopped for 12 consecutive months or more For male 10.Have you ever suffered from impotence, lack of libido ` or other symptoms related to low testosterone levels IOF, the IOF One-Minute Osteoporosis Risk Test, http://www.iofbonehealth.org. 11

1. CHẨN ĐOÁN LOÃNG XƯƠNG OVERVIEW 5/ Risk factors: FRAX model for prediction of osteoporosis fracture Age Sex Weight Height Femoral neck T_score Previous fracture 12 risk factors Rheumatoid arthritis Glucocorticoid therapy Smoking Alcohol Family s history Secondary osteoporosis FRAX (World Health Organization) http://www.shef.ac.uk/frax

OVERVIEW 5/ Risk factors: FRAX model weight Sex age height smoking Corticoid drinking Accumulate risk factors Community health care strategy Reduce fracture rate treat RA Previous fracture Parents hip fracture Secondary osteoporosis BMDF Reduce the incidence of fracture 14

OVERVIEW 5/ Risk factors: FRAX model (Clinical practice guideline) Eugene McCloskey (2009), FRAX identifying people at high risk of fracture, IOF.

OVERVIEW 6. Research of Osteoporosis fracture * Factors that relate to osteoporosis in Viet Nam - Elderly person - Early menopause - Low body weight - Low height - Corticoid therapy - Giving birth > 2 times Vũ Thị Thanh Thủy (1998), Đỗ Thị Khánh Hỷ (2007), Mai Công Danh (2008) Viet Nam: No case-control study 16

OVERVIEW 6. Research of Osteoporosis fracture * Foreign study - Tamaki (1996-2006) FRAX: Total fractures : 49,6 (6,1%) Hip fracture : 4 (0,5%) In fact :Total fracture: 43 (5,3%) Hip fracture: 8 (0.98%) - Cheung YE (1995-2009) FRAX : valuable prognosis 17

SUBJECTS AND METHOD 1. Place and duration of research - Place: Rheumatology department Bach Mai hospital -Duration: 2/2012-10/2012. 2. Method - Design Object 1: case-control study Object 2: cross sectional descriptive study 18

2. Method - Sample size + Object 1: SUBJECTS AND METHOD subjects and method 2 z 1 / 2 1 1 n 2 [log e(1 )] P1 (1 P1 ) P2 (1 P2 ) =0,05; =0,25; P1=0,5; P2=0,2 n = 338 (169 couple : case-control) + Object 2: = 0,05; = 0,15; p = 0,3 n = 203 n Z 2 1 / 2 p(1 p) ( p ) 2 19

SUBJECTS AND METHOD subjects and method 2. Method - All subjects have to satisty conditions: +Female from 50 years of age +Tested BMD (on a Hologic) + Have no previous osteoporosis treatment +Accept - Study doesnot include subjects: + Having previous or current osteoporosis treatment + Loss memory + Don t accept 20

SUBJECTS subjects and AND method METHOD 3. Subjects Object 1 183 same age couples, devided into 2 groups - Osteoporosis group + T-score -2,5 + Having previous fracture or not - Normal BMD group + T-score > - 2,5 + Having no previous fracture Object 2 426 subjects were tested BMD 21

SUBJECTS AND METHOD 4.Data collection No Variables ( object 1) Unit Method Tool 1 age Year Ask Questionnaire 2 height Cm Ask Measurment 3 weight Kg Ask Scale 4 previous spontaneous fracture Yes/No Ask Questionnaire 5 parent s previous hip fracture Yes/No Ask/Exam Questionnaire 6 Rheumatoid arthritis Yes/No Ask/Exam Questionnaire 7 longterm of taking medicine Yes/No Ask Questionnaire 8 secondary osteoporosis Yes/No Ask Questionnaire 9 BMD T-score Testing Hologic 10 giving birth Time Ask Questionnaire 11 Age of the frist period Age Ask Questionnaire 12 age of menopause/ hysterectomy Age Ask Questionnaire 13 has stopped for > 12 month Yes/No Ask Questionnaire 14 falling Time Ask Questionnaire 22

SUBJECTS AND METHOD 4.Data collection No Variables ( object 1) Unit Method Tool 1 Age Year Ask Questionnaire 2 Sex Female Questionnaire 3 Height Cm Ask measurment 4 Weight Kg Ask scale 5 Previous spontaneous fracture yes/no Ask Xray 6 Parent s previous hip fracture yes/no Ask/Exam Questionnaire 7 Lngterm of glucocorticoid therapy yes/no Ask Questionnaire 8 Rheumatoid arthritis yes/no Ask/Exam Questionnaire 9 Secondary osteoporosis yes/no Ask Questionnaire 10 BMD T-score Testing Hologic 11 Drink alcohol in excess of safe drinking limits Yes/no Ask Questionnaire 12 Current smoking Yes/no Ask Questionnaire

SUBJECTS AND METHOD 4.Data collection 6. Research protocol 426 female 50 years of age Osteoporosis 366 women (183 couples) Normal BMD FRAX 10 year probability (%) of major osteoporotic fracture Risk factors for osteoporosis Fracture risk 24

RESULTS AND DISCUSSION 1. General characteristics - 426 women - 183 couples with the same age osteoporosis normal BMD - Mean age: 59,4±7, 25

1. general characteristics 1. General characteristics No 150,83 153,29 50,29 Physical and clinical characteristics RESULTS AND DISCUSSION Osteoporosis (n = 183) Normal bone density (n = 183) p 1 Height(cm) 150,83 ± 5,60 153,29 ± 5,45 <0,001 2 Weight(kg) 50,29 ± 8,09 55,53 ± 7,95 <0,001 3 BMI (kg/m 2 ) 20,08 ± 3,19 23,64 ± 3,24 <0,001 4 Age of first perioid 16,24 ± 2,79 16,03 ± 2,24 >0,05 5 Age of menopause 48,94 ± 4,14 51,04 ± 3,84 <0,001 6 Duration of menopause (year) 11,21 ± 8,90 9,59 ± 8,05 <0,01 7 Disease related to bone metabolism 6,6% (n = 12) 4,4% (n = 8) >0,05 8 Rheumatoid arthritis 20,8% (n = 38) 12,6% (n = 23) <0,05 9 Longterm of taking medicine* 15,8% (n = 29) 8,7% (n = 16) <0,05 26

RESULTS AND DISCUSSION 2. Risk factors for osteoporosis Variables (Logistic) After exclusing confounders Chi-square p Menopause occured before the age of 45 8,94 0,01 Weight 42 kg 27,635 0,001 Correlation coefficient (r) r = 0,52 p < 0,001 Exclusion of confounders 5 steps 28

RESULTS AND DISCUSSION 2. Fracture risk FRAX model 2.1. High rate of fracture risk Total fractures Hip fractures n % n % High risk of fracture 36 8,5 26 6,1 - Tamaki: 1996-2006 FRAX: Total fractures: 49,6 (6,1%) Hip fractures: 4 (0,5%) In fact: Total fractures : 43 (5,3%) Hip fractures : 8 (0,98%) 29

RESULTS AND DISCUSSION 2 Fracture risk FRAX model 2.2. High rate of fracture risk in osteoporosis patients Total fractures Hip fractures n % n % osteoporosis 36 40,9 26 29,5 Nguyen ND (2007): osteoporosis: 45% fracture 30

CONCLUSIONS 1. Risk factors for osteoporosis in Vietnamese women from the age of 50 - Height <145 cm - Weight < 42 kg - BMI < 18,5 - Giving birth > 2 times - Early menopause - Duration of menopause > 5years - Age of the first period > 15 - Rheumatoid arthritis 2. High risk fracture following FRAX model - Menopause occured before the age of 45 - Weight 42 kg - 8,5% women in high risk of fracture and need to be treated to prevent fracture - 40,9% osteoporosis women in high risk of fracture and need to be taken care specially

RECOMMENDATIONS 1. Women above 50 need to be tested BMD 2. Well control or exclude risk factors + Weight < 42 kg + BMI < 18,5 + Giving birth > 2 times + Rheumatoid arthritis 3. Encourage using FRAX model in clinical practice in Vietnam 32

Thank you Thank you for your attention 33