Act now to prevent fragility fractures in Hong Kong
As reviewed previously, Hong Kong will bear a large and growing burden of osteoporosis and fragility fractures in the near future. This burden, however, is not inevitable. A group of local osteoporosis experts has recently reviewed both local and international data on evidence-based strategies for screening and treating people so as to reduce the risks and burden of hip fractures on a population level. Such interventions can improve treatment rates for osteoporosis, maintain quality of life for older people, reduce the burden of fragility fracture on our healthcare system, and reduce the associated economic costs to society.
After a series of meetings, the expert group formulated and agreed on three evidence-based recommendations :
· All men (≥70 years) and women (≥65 years) receive universal dual-energy x-ray absorptiometry (DXA) assessment for osteoporosis
· All men (≥70 years) and women (≥65 years) with a fracture-risk assessment-derived 10-year risk (hip fracture with bone mineral density) ≥3% should receive ≥3 years of anti-osteoporotic treatment
· Comprehensive structured assessment (including DXA) should be conducted in older patients with a history of falling
These proposals are derived from an extensive evidence base, including both local and international studies.1–7 The use of DXA scans in diagnosis, and risk assessment of osteoporosis patients is supported by both local and international guidelines.8–10 According to international studies, DXA-based screening can be cost effective,11,12 and a local analysis, drawing on data from a cohort of 4,000 men and women aged 65 years or older concluded that DXA-based screening, followed by timely treatment strategies, was cost effective for fracture prevention compared with no screening in men and women aged 65 and older.3 Several countries in the Asia-Pacific region offer full or partial reimbursement for DXA scans in older persons, including Malaysia, Japan, Singapore and Australia.13–16
For men (≥70 years) and women (≥65 years) with a fracture-risk assessment-derived 10-year risk (hip fracture with bone mineral density) ≥3%, the authors propose at least 3 years of oral alendronate therapy. This was based on long-term safety and efficacy data from large, international randomized trials,17 which is also supported by smaller local studies.4,5 Other antiresorptive drugs, such as denosumab or IV zoledronate may be offered for patients who are intolerant or have adherence problems with alendronate. Osteonecrosis of the jaw (ONJ) and atypical femoral fractures are known side-effects of antiresorptive therapies,8 but they are very rare in osteoporosis patients and appropriate precautions to minimize risk and manage these adverse events are already incorporated into local guidelines.8 Evidence from abroad suggests that in osteoporosis patients, 1,000 wrist fractures and 1,500 vertebral fractures can be prevented for every 100,000 patient-years of treatment with bisphosphonates, while only 30 cases of AFF and 0.2 of ONJ would be expected, demonstrating a highly favourable balance of benefit to risk.18 Measures to reduce the risks of falling are also a component of the response of the study group; exercise interventions and modifications to the home can reduce fall risks in community-dwelling older adults,7,19 and the group proposes these steps are incorporated into a structured intervention for older people with a history of falls.
Expectations of what the recommendations might achieve can be derived from the study of Shepstone and colleagues in the UK in which a patient questionnaire on fragility fracture risk factors was used to alert women aged 70–85 years to their fracture risk, and encourage DXA assessment and treatment in those at high risk.1 This intervention resulted in treatment being recommended for 14% of patients in the screening arm of the study; a 28% reduction in the risk of hip fracture over 5 years was observed compared with the control arm of the study.
The authors have conducted an analysis based on a recent local epidemiology study2 and data from the Hospital Authority; the analysis was discussed in detail in a recent publication.20 The analysis suggests that screening and treatment are highly likely to cost saving when both direct and indirect costs and savings are considered, and will prevent over 5,200 hip fractures over a 10-year period (Figure). If adopted, our proposals will result in approximately 1 billion Hong Kong dollars being spent on improved osteoporosis care and fracture prevention, rather than post-fracture care, an outcome that will preserve the quality of life of older people and their families. Our goal is challenging but well within our reach.