Riprogettare la salute:

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1 Riprogettare la salute: Una campagna per la prevenzione dell osteoporosi Conferenza stampa 22 gennaio 2007 ore 11 Roma via dei Frentani 4/a saletta Di Vittorio (piano terra)

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3 OSTEOPOROSI Klimt, 1905, Three ages of women

4 l osteoporosi è molto di più che una ridotta densità minerale ossea (BMD) NORMALE OSTEOPOROSI Consensus Development Conference, JAMA 2001; 285: ; 2. Dempster DW et al, JBMR

5 Osteoporosi: una malattia scheletrica sistemica caratterizzata da bassa densità ossea e da un deterioramento microarchitetturale del tessuto osseo, con un conseguente aumento della fragilità ossea e della suscettibilità alle fratture normale osteoporosi Consensus Development Conference, JAMA 2001; 285: Mosekilde et al, Bone Miner 1990; 10: 13-35

6 OSTEOPOROSI Cifosi Perdita altezza Fratture Dolore

7 Comuni siti di fratture Colonna Anca Polso

8 Come cade una persona giovane?

9 Come cade una persona anziana?

10 Fratture dell anca

11 La classica frattura dell anca

12 Il triangolo delle fratture Rischio di cadute FRATTURE Fragililtà ossea Forza di impatto

13 22 deformazioni vertebrali su 3 sono asintomatiche Le fratture vertebrali sono clinicamente rilevanti? C Cooper et al, J Bone Min Res 1992; 7:

14 Definizione operativa di osteoporosi Il valore BMD ottenuto con DEXA è lo standard di riferimento per la diagnosi di osteoporosi: T-score < -2,5

15 Interazione tra fattori genetici e ambientali sul picco di massa ossea

16 QUALITA OSSEA Un termine generico utilizzato per descrivere un gruppo di caratteristiche che influenzano la resistenza ossea microarchitettura rimodellamento mineralizzazione microdanni

17 MICROARCHITETTURA e RESISTENZA OSSEA

18 OSSO NORMALE OSTEOPOROSI

19 Effetto Eiffel MACROARCHITETTURA MICROARCHITETTURA

20 Bone Quality: la microarchitettura normale difetto qualitativo

21 NORMALE OSTEOPOROSI

22 NORMALE OSTEOPOROSI

23 Osteoporosi: l impatto della malattia

24 Prevalence and Epidemiology In the US, 8 million women and 2 million men have osteoporosis 1 1 National Osteoporosis Foundation. America s Bone Health: The State of Osteoporosis and Low Bone Mass In our Nation

25 Osteoporotic Fracture Incidence* Osteoporosis causes over 2 million fractures each year in men and women over age 50. ~300,000 hip fractures ~550,000 vertebral fractures ~400,000 wrist fractures ~810,000 fractures at other sites * Burge, et al. JBMR

26 QUALCHE CIFRA Nel mondo: 200 milioni di persone affette da osteoporosi In Italia: 5 milioni di persone affette da osteoporosi di cui il 16% tra i 50 e i 59 anni il 32% tra i 60 e i 69 anni, il 46% tra i 70 e i 79 anni In Italia: ricoveri per fratture, Nel Lazio: ricoveri Nel Lazio circa affetti da osteoporosi di cui a Roma

27 In Europa, i costi ospedalieri annuali per il trattamento dell osteoporosi sono superiori ai 4,8 bilioni di euro. Si prevede a livello mondiale nel 2050 una spesa di 131 bilioni di euro per costi sanitari. Attualmente in Spagna si verificano fratture annue con costi diretti superiori ai 126 milioni di euro ed indiretti ai 420 milioni di euro. Si prevede perciò nei prossimi anni un aumento vertiginoso dei costi per il trattamento dell osteoporosi.

28 Increased Risk Based on Heredity and Body Frame

29 Increased Risk Based on Race

30 Risk Factors for Osteoporotic Fracture Being a Caucasian or Asian postmenopausal woman Personal history of osteoporosis or fracture as an adult History of low trauma fracture in first-degree relative Small, thin frame Current smoking Advancing age

31 Osteoporosis Fracture Incidence vs. Incidence of Heart Attack, Stroke, Breast Cancer in Women Annual incidence of common diseases 2,000,000 1,500,000 1,000, , ,456,000* 223,000 hip 327,000 wrist 415,000 other sites 103,000 pelvic 389,000 vertebral Osteoporotic Fractures 345,000 Heart Attack 373,000 Stroke 269,730 Breast Cancer * Annual fracture incidence all ages Annual estimate new & recurrent MI ages 20+ Annual estimate new & recurrent stroke in women ages new cases in situ & invasive breast cancer all ages * Burge, et al. JBMR American Heart Association. Heart Disease and Stroke Statistics 2007 Update American Cancer Society. Surveillance Research

32 Risk of Another Vertebral Fracture Is Higher in Year Following New Fracture 20% will have new vertebral FX within one year Percent (%) of Patients Overall Number of Baseline Vertebral Fractures p<0.05 vs. patients with no vertebral fractures (12-Fold Increased Risk) Lindsay R, et al. JAMA Jan 17;285(3):320-3.

33 Calcium Vitamin D Exercise Fall prevention Nutrition and weight gain Stop smoking

34 Universal Prevention/Treatment Strategies Counsel all patients on risk reduction Instruct all patients on adequate daily intake of calcium and vitamin D Provide guidelines for regular participation in weight-bearing and muscle strengthening exercises to reduce risk of falls and fractures Provide strategies for fall prevention Counsel all patients on avoiding tobacco smoking and excessive alcohol intake

35 For Strong Bones: Calcium Recommended Calcium Intake Children and Adolescents mg/day 11 through 3 years through 8 years through 18 years 1300 Adult Adult Women and Men 1919 through 49 years 1000 > > 50 years 1200 Pregnant and Lactating Women <18 <18 years 1300 >19 >19 years 1000 Source: National Academy of Sciences, 1997

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37 H E A L T H Y E A T I N G F O R S T R O N G B O N E S

38 Sun Exposure and Vitamin D Sunscreens block production of Vitamin D in the skin Vitamin D supplementation is advisable for those unable to have sun exposure without sunscreen or who are housebound or live in northern latitudes

39 The Role of Exercise in Prevention and Treatment Benefits of exercise related to osteoporosis: Decreased risk of falling Improved bone mass and strength Enhanced muscle strength Improved balance, flexibility, and posture Improved cardiovascular fitness Improved depression Recommend both weight-training training and resistance-training training exercises

40 Recommended Exercises for Younger, Physically Able Patients Walking Stair climbing Dancing Jogging Sports (racquet sports, soccer, etc.

41 Basic Balance Training Simple Balance Training can be taught in the office Stand facing a counter or table top Hold on with both hands, bend one knee bringing foot behind you; hold for a count of 5 Repeat with the other foot Repeat sequence holding on with one hand Repeat sequence holding on with a fingertip Repeat sequence without holding on Repeat from beginning balancing on one leg with eyes closed

42 Fall Prevention in the Home Use handrails on stairs, in bathroom Keep rooms free of clutter Keep floor surfaces clean but not slippery Wear supportive, low-heeled shoes. Do not walk in socks or floppy slippers Use 100 watt bulbs in all rooms Install ceiling lighting in bedrooms Use rubber matt in shower/tub Keep a flashlight at bedside Check posture in mirror often

43 General Guidelines for Exercise in Osteoporosis Patients Avoid exercises involving forward flexion of the spine or bending forward from the waist Avoid exercises that twist or jerk the spine Participate in exercise programs that allow one foot to remain on the floor at all times

44 Fall Prevention in the Home Keep floors clutter free Use a portable phone and keep phone and electrical wires out of walkways Place skid-proof backing on carpets and rugs Keep a week s supply of prescription medications Arrange for daily contact with family or neighbor Contract with a 24-hour monitoring service in case of emergency

45 FDA-Approved Approved Pharmacologic Options

46 US FDA-Approved Approved Pharmacologic Options Antiresorptives (bone retaining): Bisphosphonates (Alendronate, Risedronate,, and Ibandronate) Calcitonin Estrogen/Hormone Therapy Raloxifene Anabolics (bone forming): Parathyroid Hormone Therapy (PTH 1-34, 1 teriparatide)

47 Parathyroid Hormone (1-34) (PTH) or Teriparatide PTH (1-34) is classified as an anabolic agent that builds new bone PTH (1-34) is administered daily by subcutaneous injection PTH (1-34) decreases the risk of vertebral fractures and nonvertebral fragility fractures after an average of 18 months of therapy Writing Group for the Women's Health Initiative. JAMA. 2002; 288(3):

48 Teriparatide Indications Postmenopausal women with osteoporosis at high risk of fracture Men with primary or hypogonadal osteoporosis at high risk of fracture High-risk includes: Men and women with previous osteoporotic fracture(s) Men and women with multiple risk factors for fracture Men and women with extremely low BMD (-3( 3 and below) Those who are unresponsive or intolerant to other osteoporosis therapies US Food and Drug Administration. FDA Talk Paper. November 26, 2002.

49 Teriparatide Administration Teriparatide is available as a daily injection Patients are taught to self-administer the medication that comes in a pre-filled, metered 28-day syringe

50 Teriparatide BMD Results Compared to placebo, 20 mcg of teriparatide increased lumbar spine BMD by 9 more percentage points, respectively 1 Compared to placebo, the 20 mcg dose increased BMD in the femoral neck by 3 more percentage points 1 BMD effects were similar regardless of patient age or baseline BMD 2 1 Neer RM, et al. N Engl J Med. 2001;344(19): Marcus R, et al. J Bone Miner Res (1):18-23.

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55 Il questionario è stato inviato a persone in pensione È attesa una risposta minima del 30%

56 GRAZIE PER L ATTENZIONE Francesco Riva