Prevalence of osteoporosis in Middle Eastsystemic literature review

Mohy Taha, MDAOCID Clinical Research FellowKantonsspital Aarau, Switzerland

10th ECOO14-16 April 2011

2

A medical revolution

• 1958: Foundation of the „Arbeitsgemeinschaft für Osteosynthese / AO“ (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

AO Clinical Investigation & Documentation

Davos, headquarters Dübendorf/Zürich office

Step 1

Idea

Step 2

Planning

Step 3

Implementation

Step 4

Reporting Results

Step 5

Publication

Submission

Revision

Acceptance

Define clinical question and specific aims

Study protocol

Regulatory affairs

Monitoring

Follow-up

Statistics

Clinical Research

Good Clinical Practice (GCP) training

From Cairo to Clinical Research

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 PFPharmacological 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

Publications

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

United Nations World Population Prospects, 2008

Change in life expectancy 1950 - 2045

75% of elders developing countries

2050 !

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

hhhgh

Disease of the elderly?

Andrade, Tibia & Fibula fracture, Cruz Azul vs Tecos 12/07/07

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

In Europe1

• € 31 billion/year• € 76 billion by 2050

In Middle East, Iran2

• $ 8-16 million/year • 2 million people at risk of fracture

1Kanis and Johnell, Osteoporos Int. 2005; 16 Suppl 2:S3-72Larijani B, 1st International Osteoporosis Seminar in Iran. Teheran, Iran; 2004

Burden of osteoporotic fractures

Orthopedic Surgeons?

• Fx often 1st indication for Osteoporosis1

• 1st (only) to meet fracture patients1

• 80% (2737/3422) don’t measure theBMD after 1st fx2

• 75% (2310/3422) lack appropriate knowledge about osteoporosis2

1 Bouxsein et al. J Am Acad Ortho Surg. 2004; 12:385-952 Dreinhöfer 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

• Bahrain

• Egypt

• Iran

• Iraq

• Jordan

• Kuwait

• Lebanon

• Libya

• Palestine

• Oman

• Saudi Arabia

• Syria

• Tunisia

• UAE

Middle East?

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

Materials & methods

Disease:• (Osteoporosis OR Osteopenia OR Osteopenic OR Osteoporotic OR

bmd OR bone mineral density)AND

Location:• (“Middle 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 “Saudi Arabia” OR “Saudi Arabian” OR Syria OR Syrian OR Tunis OR Tunisian OR UAE OR “Emirates” OR Emirati)

AND

Epidemiology: • (Incidence OR prevalence)

Search criteria on 03.03.11

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 locally published

• 5 WHO (EMRO)

• 85 total articles

• 15 articles (EGY)

WHO criteria for diagnosis of osteoporosisComparison of a patient’s BMD with the mean for normal young adult population

Derived from European & North American postmenopausal women

T-score

Normal -1 and above

Osteopenia -1 to -2.5

Osteoporosis -2.5 and below

Severe osteoporosis

-2.5 and below with fragility fracture

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

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

Osteopenia %

Osteoporosis %

Males (43) 18.6 9.3

Females (31) 22.5 16.1

Authors # patients Age (mean) Method Osteo-penia

Osteo-porosis

Referencepopulation

Rashed et al(2011)

18000 60-80 (66.1) DXA 53.7 30.9 --

Hussein et al(2009)

71 22-48 (34) U-Sono 16.9 1.4 INT

Moussa et al(2003)

2886 35-89 (--) DXA 55.7 12.5 EGY

Taha et al(2003)

1000 18-89 (47.3) U-Sono 17.6 47.4 INT

Al-Bahnasy(2003)

5587 40-65 (--) DXA 9.5 12.9 INT

Nahia(2003)

1200 40-66 (--) CT -- 10 INT

Rashed et al(2000)

1243 20-84 (--) DXA 34.7(43.7) 11.2(25.4) EGY(INT)

El-Husseiny et al (2000)

1190 20-89 (54.1) DXA -- 22.3 --

31177

osteopenia

26.9 %

osteoporosis

18.6 %

Osteoporosis in Women

Osteoporosis in Postmenopausal women

Authors # patients Age (mean) Method Osteo-penia

Osteo-porosis

Reference

Rashed et al(2011)

18000 60-80 (66.1) DXA 53.7 30.9 --

Moussa et al(2003)

2886 35-89 DXA 55.7 12.5 EGY

20886

osteopenia

53.9 %

osteoporosis

28.4 %

Osteoporosis in Men

Authors # patients Age (mean) Method Osteo-penia

Osteo-porosis

Reference

Al-Gendi et al(2007)

100 30-65 (44.7) U-Sono 26 11 EGY

Salem et al(2000)

55 20-89 (54.9) DXA -- 41.8 --

155

osteopenia

26 %

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

• Quantify the size of the problem in the Middle East

• Recognize research deficits

• Identify research opportunities in the region

• Experience in literature reviews

Benefits

February-March 2011:• Searching • Collection of full articles

April 2011:• Reading • Data extraction

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

Timetable

Questions?

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

Exercise helps fighting osteoporosis!