osteoporosis: identification of high risk individuals leonard koh consultant physician &...

Osteoporosis: Identification of High Risk Individuals

Leonard Koh

Consultant Physician & EndocrinologistGleneagles Medical Centre

Scope

• Fracture risk in Asians

• Risk factors for osteoporosis

• Using risk factors for diagnosis

• Risk factors for fracture

• Using risk factors for treatment

Regional distribution of hip fractures in women 65 years (%)

2050

20.9

Asia Europe N America Latin America

Russia Middle East Oceania Africa

31.2

28.6

7.1

8.82.3

0.80.2

51.1

13.0

11.9

12.5

4.45.7 0.7 0.6

1990

Cooper, Osteoporos Int 1992;2:285

Population Women

ASIANS• Singapore 1991-98 402• Singapore 1955-62 75• Malaysia 1997-98 199• Malaysia 1989 108• California 1983-84 337

CHINESE• Singapore 1991-98 410• Singapore 1957-63 106• Hong Kong 1997-98 429• Hong Kong 1966 149• Taiwan 1996-2000 451• Shenyang 1994 87• Beijing 1990-92 96

MALAY• Singapore 1991-98 264• Singapore 1957-63 44

INDIAN• Singapore 1991-98 361• Singapore 1957-63 565

Age-adjusted* hip fracture incidence rates per 100,000 in 50 year olds

* to 1985 US population

Population Women

JAPANESE• Wakamaya 1992 332• Tottori 1998-2001 304• Tottori 1986-87 206• Okinawa 1984-85 287• Hawaii 1979-81 247

KOREAN• Honam 2001 176• Honam 1991 41

THAI• Chiang Mai 1997-98 251

ARAB

• Kuwait 1992-95 295• Shiraz 2000-03 505

CAUCASIAN• California 1983-84 553• Hawaii 1979-81 579• Stockholm 1972-81 622

Hip Fractures in Singapore 1991-1998

Koh, Osteoporos Int 2001:12:311-8** 50 year olds, standardized to 1985 US population

168

410

71

264

128

361

0

50

100

150

200

250

300

350

400

450 Chinese

Malay

Indian

Inci

den

ce r

ate

pe

r 1

00,0

00

**

(95%

co

nfid

enc

e in

terv

als)

Males Females

* p<0.05

* **

*

Bone density & hip geometry in a multiracial population

Goh, J Clin Densitom 2004;7:406-412

• n=1575: Chinese 1222 (77.6%), Malays 122 (7.7%), Indian 231 (14.7%)• age 20-59 yr

* p < 0.05

0.941

0.879

0.967

0.888

0.9460.968

0.5

0.7

0.9

1.1

Chinese Malay Indian

20 - 29 yr 50 - 59 yr

Age group (yr)

Fe

mo

ral n

eck

BM

D (

g/c

m2) **

9.879.67 9.69

8

9

10

11

CH MA INH

ip a

xis

len

gth

(cm

)

*

*

Borgstrom, Osteoporos Int 2006;17:1459-71

Hip fracture risk among women in the general population

Barrett-Connor, JBMR 2005;20:185-94

Ethnic differences in fracture risk

National Osteoporosis Risk Assessment (NORA)

Mean T-score (SD) -0.89 -0.39 -1.12 -1.13 -1.22

Incidence of 1.5 0.8 1.8 1.7 0.7all fractures (%)

1 0.55 0.96 1.2 1.051 0.52 0.87 0.95 0.320

0.2

0.4

0.6

0.8

1

1.2

1.4

Caucasian African-American

NativeAmerican

Hispanic-American

Asian-American

Odds of osteoporosis

Relative risk of fracture

Odd

s /

Rel

ativ

e ris

k

Falls among Asian vs Caucasian women

Davis, J Clin Epidemiol 1997;50:589-94. Aoyagi, J Bone Miner Res 1998;13:1468-74

Reference Population Risk ratios (95% CI)

Prudham 1981 65 yr+, Northeast UK 1.8 (1.6-2.1)

Blake 1988 65 yr+, Nottingham UK 2.2(1.9-2.6)

Wickham 1989 65 yr+, National UK 2.2 (1.9-2.6)

Winner 1989 Postal survey, Oxford, UK 1.4 (1.1-1.7)

Campbell 1989 70 yr+, New Zealand 1.8 (1.5-2.2)

O’Loughlin 1993 65 yr+, Montreal, Canada 1.4 (1.1-1.8)

Lukinen 1994 70 yr+, Finland 1.8 (1.4-2.1)

Davis 1997 Japanese, Hawaii, USA 0.8 (0.6-1.1)

Aoyagi 1998 65 yr+, Mitsui-gun, Japan 1.0

Costs of osteoporosis

• Mortality

• Morbidity

• Economic

• Social

Scope






Definition

NIH Consensus Development Panel 2001

Osteoporosis:bone disorder

Reducedbone strength

Increasedfracture risk

Bone density

DXA hip & spine

+ Bone quality

?

Kung, J Bone Miner Res 2007;22:1080-7

Ten-year probability of osteoporotic fractures in Chinese women according to risk factors & BMD

• 1435 community dwelling, post-menopausal women• Mean age 63 years

Bone mass life-line

0 10 20 30 40 50 60 70

BO

NE

MA

SS

Full genetic potential Menopause

Inadequate environmental factors High fracture risk

AGE

modified from Heaney, Osteoporos Int 2000

HEREDITY

EXERCISE / LOADING

CALCIUM & VIT D INTAKE

STRUCTURAL ERRORS

Increased bone loss

Determinants of BMD

Pre-menopausal Post-menopausal p

Subject number 262 269 -

Age (yr) 33 65 <0.0001

Height (cm) 159 152 <0.0001

Weight (kg) 54 55 ns

Age at menarche (yr) 13 15 <0.0001

Age at menopause (yr) - 49 -

Calcium intake (mg/d) 605 635 ns

Isoflavone intake (mg/d) 33 25 ns

Smoker % 4 3 ns

Drinker % 7 1 <0.05

Physical activity score 3.4 3.5 ns

LS BMD (g/cm2) 0.977 0.733 <0.0001

FN BMD (g/cm2) 0.744 0.597 <0.0001

Lau, Bone 2005;36:700-9

ER, ER, CASR, COLIA1, LRP5, VDR

Premenopausalwomen

Postmenopausalwomen

Determinants of BMD

Lau, Bone 2005;36:700-9

80.6

15.9

3.5

Weight

Genetic

Age

Menarche age

Calcium intake

Others4.4

2.2

25.1

68.3

LS BMD LS BMD

24.3

75.7

14.158.8

23

1.10.7

FN BMD FN BMD

Factors affecting bone mass

Other (weight, medication, etc)

Exercise

Calcium deficiencyHeredity

Heaney, AJCN 1991 Pocock JCI 1987, Pocock JCI 1986, Kelly BMJ 1990

Specker, Am J Clin Nutr 2000

Heredity75-80%

Diet40%

Exercise40% Other (weight,

medication, etc)

Scope






Risk factors for low bone mass & fracture:� Personal history of fracture as an adult� History of fracture in a first degree relative (especially maternal)� Low body weight & older age � Early natural or surgical menopause (< 45 yr), prolonged amenorrhea >1 yr� Drugs e.g. corticosteroids, excess thyroxine, anticonvulsants� Ongoing disease e.g. hypogonadism, rheumatoid arthritis, malabsorption� Prolonged immobilization, poor health or frailty� Current cigarette smoking� Alcohol abuse� Lifelong low calcium intake � Lack of regular physical activity

Risk factors for fracture independent of bone mass:� Previous falls in the past year� Strokes, poor balance, weak quadriceps muscle strength� Impaired eyesight despite adequate correction� Drugs e.g. sedatives, polypharmacy� Environmental factors e.g. slippery floors, inadequate lighting

Risk Factors for Osteoporosis

MOH CPG 2002

Measure BMD

More risk factors for osteoporosis

More likely to have osteoporosis

Bone densitometry indications Prevalence (%)Prolonged amenorrhea <1Late puberty after age 15 yr 5.6Menopause before age 45 yr 19.2Menopause after age 45 yr with 2 or more additional risk factors 44.1 (No HRT, FHx OP, BMI<25, cigarettes>10/d, alcohol>4 glasses/d,

physical activity<30 min/d, low calcium diet)Hypogonadism <1History of non-traumatic fractures <1Fortuitous discovery of osteopenia <1History of diseases affecting the skeleton 6.9History of long-term immobilization (>3 mth) <1Long-term use of medication affecting the skeleton 12.8

Use of risk factors in screening for osteoporosis

• n =3,998, female 92%, age ~60 yr

• Prevalence of osteoporosis: FN 23%, LS 23%, any site 31%

Ben Sedrine, Osteoporos Int 2002;13:434-442

Presence of at least one risk factor 66.6

Probability of having osteoporosis with at least one risk factor : 35%

Probability of having osteoporosis with 2 or more risk factors : 36%

Year Instrument Factors used in scoring system

1992 Ribot et al age, wt, ht, age at menarche, menopause, yr since menopause, OA

1998 NOF age 65 or age <65 & one of: low wt, # after age 40, FHx #, smoking

1998 SCORE age, wt, race, RA, # after age 45, estrogen

1998 SOFSURF age, wt, smoking, # after age 50

2000 ORAI age, wt, no estrogen

2000 ABONE age, wt, never estrogen

2001 OSTA / OST age, wt

2002 OSIRIS age, wt, prior #, estrogen

2004 DOEScore age, wt, prior #

Scoring systems to select postmenopausal women for BMD

Osteoporosis Self-assessment Tool for Asians

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85-89

45-49 50-54 55-59 60-64 65-69 70-74 75-7940-44

Weight (kg)

Age(yr)

LOW RISK*probability 1 - 3%

HIGH RISK*probability 46 - 61%

MODERATE RISK*probability 10 - 15%

* probability of finding osteoporosis on BMD

Koh, Osteoporos Int 2001;12:699

RISK FACTORS

� Previous fracture

� Family history of fracture

� Poor health & frailty

� Cigarette smoking

� Early menopause

� Alcohol abuse

� Prolonged immobilization

� Drugs e.g. corticosteroids

� Ongoing disease

Send for DXA+ risk factors

Truncate [Weight (kg) x 0.2] – Truncate [Age (yr) x 0.2]Truncate 0.2 x [Weight (kg) – Age (yr)]

-1

-2

-3

-4

-5

-6

0 1 3 4 5 62

Osteoporosis Self-Assessment Tool (OST) Validation

Author Study population Cut-offs Low risk Medium risk High risk

Koh 2001 8 Asian countries -1, -4 3 15 61

Japan -1, -4 1 10 44

Koh 2001 Singapore -1, -4 1 10 46

Saetung 2008 Thailand -1, -4 2 6 40

Geusens 2002 USA multicentre 1, -3 4 23 57

Rotterdam 1, -3 4 22 57

Richy 2004 Belgium 1, -3 6 22 60

Cadarette 2004 Canada (chart) 1, -3 4 17 58

Canada (equation) 1, -3 2 19 56

Gourlay 2005 Belgium (45-64 yr) 3, -2 1 6 28

Belgium (65 yr) 1, -5 3 16 57

Percent with osteoporosison FN BMD (%)

What OSTA/OST does and does not do

Guides decision to do BMD

Does not guide lifestyle decisions

Does not guide decision to treat

van Staa, Q J Med 2006;99:673

THIN index

FRACTURE index

Rotterdam risk score

Body weight criteria

ORAI

OST

Clinical score for estimating 5-year hip fracture risk

Risk factors for THIN index:Age, fracture history, fall history, BMI, smoking,chronic disease, CNS meds, early menopause

“A simple scheme that only included age and weight (the Osteoporosis Self-Assessment Tool) found (hip) fracture risks similar to our more complex scheme.”

Prevalence of vertebral deformities according to OSTA index group

Saetung, J Bone Miner Metab 2008;26:47

19.2

7.9

2.8

0

2

4

6

8

10

12

14

16

18

20

High risk Medium risk Low risk

Pre

vale

nce

(%)

Scope






Risk factors for hip fracture in women

Asian Osteoporosis Study

• (451 men) & 725 women with hip fractures• Age 50 yr and over• Singapore, Malaysia, Thailand, Philippines

Risk factor Risk ratio (95% CI)

Dietary calcium intake

Highest quartile 1.0

Lowest 3 quartiles (<498 mg/d) 2.0 (1.5-2.8)

Load-bearing activity in immediate past

Everyday 1.0

Weekly 1.1 (0.7-1.7)

None 2.0 (1.4-2.7)

Vigorous sports activity at 25-49 yr (no vs yes) 7.2 (4.0-13.0)

Smoking (Ex- or current vs non-) Not included

Alcohol (7 days/wk vs non-) 2.9 (1.0-8.6)

Lau, JBMR 2001;16:572-80

Risk factors for hip fracture in women

Risk factor Risk ratio (95% CI)

Falls in last 12 months: None 1.0

Once 1.4 (0.9-2.1)

Twice or more 3.0 (1.8-4.8)

History of fractures from age 50 yr (yes vs no) 1.8 (1.1-2.9)

History of stroke (yes vs no) 3.8 (2.0-7.1)

Drug history: Sedatives 2.5 (1.0-6.3)

Thyroid drugs 7.1 (2.0-25.9)

Body height quartile:

highest (men ≥1.69m, women ≥1.56m) vs

lowest (men <1.59m, women <1.48m) 2.0 (1.3-3.0)

Age at menopause 1.5 (1.0-2.1)

Lau, JBMR 2001;16:572-80

Asian Osteoporosis Study

Scope






Definition BMD T-score Action

Normal -1 SD Repeat BMD after a time interval

Osteopenia -1 to -2.5 SD Consider prevention. With multiple risk factors: consider treatment

Osteoporosis -2.5 SD Consider treatment

Severe Osteoporosis

-2.5 SD + fracture Advisable to treat

Most guidelines*

Treatment based on BMD & Fractures

* NOF, AACE, EFFO, UK, Australian, Singapore, Malaysia

Definition BMD T-scoreat baseline

Treatments shown to reduce vertebral fractures

Normal -1 SD nil

Osteopenia -1 to -2.5 SD• Unselected• <-1.5 SD

HRT** RLX, STR

Osteoporosis -2.5 SD, no fracture ALN*, RIS*, RLX, STR

Severe osteoporosis Vertebral fracture ALN**, RIS**, ZOL**, STR**, RLX, PTH*, HRT*, IBNETI, CTN, PAM

Results of Treatment Trails by BMD & Fractures

Multiple clinical riskfactors for fracture

If BMD not known nil

* also reduce non-vertebral fractures** also reduce non-vertebral and hip fractures

Subgroup:elderly, osteoporotic

-2.5 SD, no fracture, Age 80 yr

STR*, RIS, PTH

Wainwright, J Clin Endocrinol Metab 2005;20:1185-94

Hip fracture and BMD

Study of Osteoporotic Fractures

54% of women with incident hip fractures (n=243) did not have

osteoporosis

17% of women (n=8065)had osteoporosis

Proportion with

fractures 8.2%

Proportion with fractures

2.0%

Better way to assess fracture risk?

2.4

3.2

4.3

4.6

4.0

2.6

4.2

4.5

1.8

3.0

4.1

5.5

6.0

5.0

3.3

5.4

5.8

2.3

3.8

5.1

7.1

7.7

6.3

4.1

7.0

7.4

2.8

4.7

6.5

9.0

9.9

8.0

5.3

9.1

9.4

3.5

5.9

8.2

11.5

12.7

10.0

6.7

11.8

12.0

4.3

7.4

10.4

14.6

16.2

12.6

8.5

15.2

15.3

5.6

9.2

13.0

18.3

20.5

15.6

10.7

19.4

19.1

6.6

11.3

16.2

22.8

25.6

19.3

13.4

24.5

23.8

8.1

14.1

20.2

28.4

31.8

23.9

16.8

30.8

29.4

10.0

21.3

30.6

42.3

46.4

35.5

26.0

46.2

42.7

15.0

2.4

3.2

4.3

4.6

4.0

2.6

4.2

4.5

1.8

3.0

4.1

5.5

6.0

5.0

3.3

5.4

5.8

2.3

3.8

5.1

7.1

7.7

6.3

4.1

7.0

7.4

2.8

4.7

6.5

9.0

9.9

8.0

5.3

9.1

9.4

3.5

5.9

8.2

11.5

12.7

10.0

6.7

11.8

12.0

4.3

7.4

10.4

14.6

16.2

12.6

8.5

15.2

15.3

5.6

9.2

13.0

18.3

20.5

15.6

10.7

19.4

19.1

6.6

11.3

16.2

22.8

25.6

19.3

13.4

24.5

23.8

8.1

14.1

20.2

28.4

31.8

23.9

16.8

30.8

29.4

10.0

21.3

30.6

42.3

46.4

35.5

26.0

46.2

42.7

15.0

Kanis, Osteoporos Int 2001;12:989-95

Ten-year probability of any osteoporotic fracture (hip, spine, forearm, humerus) according to BMD

Swedish women

+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0

BMD T-score

50

60

70

80

65

55

75

85

45

Ag

e (y

r)

Age-adjusted* hip fracture incidence rates per 100,000 in 50 year olds

Population Women

JAPANESE• Wakamaya 1992 332• Tottori 1998-2001 304• Tottori 1986-87 206• Okinawa 1984-85 287• Hawaii 1979-81 247

KOREAN• Honam 2001 176• Honam 1991 41

THAI• Chiang Mai 1997-98 251

ARAB• Kuwait 1992-95 295• Shiraz 2000-03 505

CAUCASIAN• California 1983-84 553• Hawaii 1979-81 579• Stockholm 1972-81 622

Population Women

ASIANS• Singapore 1991-98 402• Singapore 1955-62 75• Malaysia 1997-98 199• Malaysia 1989 108• California 1983-84 337

CHINESE• Singapore 1991-98 410• Singapore 1957-63 106• Hong Kong 1997-98 429• Hong Kong 1966 149• Taiwan 1996-2000 451• Shenyang 1994 87• Beijing 1990-92 96

MALAY• Singapore 1991-98 264• Singapore 1957-63 44

INDIAN• Singapore 1991-98 361• Singapore 1957-63 565

* to 1985 US population

International variations in hip fracture probabilities

Kanis, J Bone Miner Res 2002;17:1237-44

1.5

2.0

2.7

2.9

2.5

1.6

2.6

2.8

1.1

1.9

2.5

3.4

3.7

3.1

2.0

3.3

3.6

1.4

2.4

3.2

4.4

4.8

3.9

2.5

4.3

4.6

1.7

2.9

4.0

5.6

6.1

5.0

3.3

5.6

5.8

2.2

3.7

5.1

7.1

7.9

6.2

4.2

7.3

7.4

2.7

4.6

6.4

9.1

10.0

7.8

5.3

9.4

9.5

3.5

5.7

8.1

11.3

12.7

9.7

6.6

12.0

11.8

4.1

7.0

10.0

14.1

15.9

12.0

8.3

15.2

14.8

5.0

8.7

12.5

17.6

19.7

14.8

10.4

19.1

18.2

6.2

13.2

19.0

26.2

28.8

22.0

16.1

28.6

26.5

9.3

Extrapolation for Singapore women

+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0

BMD T-score

50

60

70

80

65

55

75

85

45

Ag

e (y

r)

1.5

2.0

2.7

2.9

2.5

1.6

2.6

2.8

1.1

1.9

2.5

3.4

3.7

3.1

2.0

3.3

3.6

1.4

2.4

3.2

4.4

4.8

3.9

2.5

4.3

4.6

1.7

2.9

4.0

5.6

6.1

5.0

3.3

5.6

5.8

2.2

3.7

5.1

7.1

7.9

6.2

4.2

7.3

7.4

2.7

4.6

6.4

9.1

10.0

7.8

5.3

9.4

9.5

3.5

5.7

8.1

11.3

12.7

9.7

6.6

12.0

11.8

4.1

7.0

10.0

14.1

15.9

12.0

8.3

15.2

14.8

5.0

8.7

12.5

17.6

19.7

14.8

10.4

19.1

18.2

6.2

13.2

19.0

26.2

28.8

22.0

16.1

28.6

26.5

9.3

Relative probability for Singapore = 0.62

Ten-year probability of any osteoporotic fracture (hip, spine, forearm, humerus) according to BMD

Based on Swedish data

1.5 1.9 2.4 2.9 3.7 4.6 5.7 7.0 8.7 13.2

2.0 2.5 3.2 4.0 5.1 6.4 8.1 10.0 12.5 19.0

2.7 3.4 4.4 5.6 7.1 9.1 11.3 14.1 17.6 26.2

2.9 3.7 4.8 6.1 7.9 10.0 12.7 15.9 19.7 28.8

2.5 3.1 3.9 5.0 6.2 7.8 9.7 12.0 14.8 22.0

1.6 2.0 2.5 3.3 4.2 5.3 6.6 8.3 10.4 16.1

2.6 3.3 4.3 5.6 7.3 9.4 12.0 15.2 19.1 28.6

2.8 3.6 4.6 5.8 7.4 9.5 11.8 14.8 18.2 26.5

1.1 1.4 1.7 2.2 2.7 3.5 4.1 5.0 6.2 9.3

50

60

70

80

65

55

75

85

45

Age

(yr

)

+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0

BMD T-score

50

60

70

80

65

55

75

85

45

+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0

BMD T-score

Extrapolated fromKanis, Osteoporos Int 2001;12:989-95 Kung, J Bone Miner Res 2007;22:1080-7

Ten-year probability of any osteoporotic fracture according to age and BMD

Hong KongExtrapolation for Singapore

Relevant databases for Asians:• China• Japan• US (Asian)

http://www.shef.ac.uk/FRAX/index.htm

Fracture risk for countries other than US

(Asian), Japan & China?

What threshold for intervention?

Are osteoporosis drugs effective based on

clinical fracture prediction models?

Issues

Age

(yr

)

BMD T-score

50

60

70

80

65

55

75

85

45

+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0

BMD T-score


50

60

70

80

65

55

75

85

45

+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0

50

60

70

80

65

55

75

85

45

+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0

50

60

70

80

65

55

75

85

45

+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0

FRAX (Japan)FRAX: US (Asian)

Age

(yr

)

Wt 54.9 kgHt 152 cm

Any fracture

10%

15%

20%

Any fracture

Absolute 10-year hip fracture risk (vertical bars) at which it is cost-effective to treat (lines) in the USA

Tosteson, Osteoporos Int 2008;19:437-47

0

3

6

9

12

15

50 60 70 80

Age (yr)

10-

yr H

ip F

ract

ure

Pro

bab

ility

, %

Tosteson, Osteoporos Int 2008;19:437-47

Cost-effectiveness thresholds for US white women based on treatment cost and willingness-to-pay (per QALY gained)

Age

(yr

)

BMD T-score

50

60

70

80

65

55

75

85

45

+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0

BMD T-score


50

60

70

80

65

55

75

85

45

+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0

50

60

70

80

65

55

75

85

45

+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0

50

60

70

80

65

55

75

85

45

+1.0 +0.5 0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -4.0

FRAX (Japan)FRAX: US (Asian)

Age

(yr

)

Wt 54.9 kgHt 152 cm

Hip fracture

2%

3%

5%

Any fracture

10%

15%

20%

• Fracture incidence is rising in Asians

Conclusions

• Epidemiological differences in hip fracture risk exist between Asians and other races, and within Asian ethnicities

• Risk factors for low BMD appear similar to other populations, but many occur in a minority

• Risk factors for low BMD could be used in clinical scoring systems as part of screening strategies for detecting osteoporosis

• Risk factors for fracture appear similar to other populations, are quantifiable, and have been used in models to predict 5- to 10- year fracture risk to assist in treatment decisions

• These models need to be tailored for each country

• There are limitations in BMD-based treatment algorithms

osteoporosis: identification of high risk individuals leonard koh consultant physician &...

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asians risk factors

diagnosis risk factors

scope fracture risk

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chinese singapore

indian singapore

treatment slide

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