Chandran, Manju

Khan, Aysha Habib

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eCommons@AKU

eCommons@AKU Department of Pathology and Laboratory Medicine Medical College, Pakistan 4-1-2021 Need for clinical guidelines for management of osteoporosis and way forward for Pakistan Aysha Habib Khan Manju Chandran Follow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_pathol_microbiol  Part of the Endocrinology, Diabetes, and Metabolism Commons, Family Medicine Commons, Pathology Commons, and the Rheumatology Commons EDITORIALJournal  of  the College of  Physicians and Surgeons Pakistan 2021,  Vol.  31(04):  371-372 371Need for Clinical Guidelines for Management ofOsteoporosis and Way Forward for PakistanAysha Habib Khan1 and Manju Chandran21Section of Chemical Pathology, Department of Pathology & Laboratory Medicine & Medicine, Aga Khan University, Karachi, Pakistan2Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, DUKE-NUS Graduate MedicalSchool; Asia Pacific Consortium on Osteoporosis, SingaporeOsteoporosis is a global epidemic, characterised by low bonemass and altered micro-architecture of the bone.1 The popula-tion at risk of fractures due to fragile bones is expected toincrease by over two-folds by the year 2040; and the burdenrises with ageing populations.2  The situation is,  especially,alarming in the Asia-Pacific region, where the population over65 years is expected to quadruple by 2050, with over half ofthe  hip fractures in the world predicted to occur in the Asia-Pa-cific by that year.3The  Asia-Pacific  Consortium  on  Osteoporosis  (APCO)  waslaunched in May 2019. Its vision is to reduce the burden ofosteoporosis and its associated complication of fractures inthe Asia- Pacific. APCO is comprised of 39 experts in osteo-porosis from 19 countries and regions.4 APCO determined thatthe existing clinical guidelines for osteoporosis in countries inthe Asia- Pacific were too varied in scope and recommenda-tions, through a comprehensive and comparative review. Inaddition, there are many low- and middle-income countries(LMICs) where no guidelines exist.The  first  APCO’s  project  was,  therefore,  to  formulateharmonised pan Asia-Pacific clinical practice standards (TheFramework) for the screening, diagnosis, and management ofosteoporosis. A ‘5IQ’ approach identification, investigation,information,  intervention,  integration  and  quality,  wasemployed to identify key elements in the various national andregional guidelines for consideration to be included as stan-dards of care. APCO members then shaped The Framework byreaching  a  consensus  using  the  Delphi  technique  throughmultiple rounds of structured questionnaires.5 Correspondence  to:  Prof.  Aysha  Habib  Khan,  Departmentof  Pathology  &  Laboratory  Medicine,  The  Aga  KhanUniversity,  Stadium  Road,  P.O.  Box  3500,  Karachi  74800,PakistanE-mail:  aysha.habib@aku.edu.....................................................Received: March 22, 2021;  Revised: April  06, 2021;Accepted:  April  08,  2021DOI:  https://doi.org/10.29271/jcpsp.2021.04.371The Framework is a guidance document, proposing minimumpractice standards for osteoporosis management, focusing ona  broad  range  of  high-risk  groups,  including  patients  whoalready have had a fragility fracture, patients who are at ahigher risk according to country-specific fracture interventionthreshold and other high-risk groups, such as patients livingwith conditions/or are on medications that predispose to boneloss. An aspirational and readily measurable guidance, it ishoped  that  the  clinical  guidelines  on  osteoporosis  in  thevarious  countries  of  the  Asia-Pacific  will  be  benchmarkedagainst the scope and standards of care proposed in the frame-work.In Pakistan, accurate data on osteoporosis is absent due tolimited number of epidemiological studies. Available studiesreport lack of DEXA machines availability with a high burden ofosteoporosis on heel ultrasound scanning. Clinical guidelinesare  non-existent;  and  there  is  no  available  report  ofcompliance to any action plan in clinical practice throughoutPakistan.6However, prevalence and associated complications of osteo-porosis  are expected to rise due to an aging population,  asedentary lifestyle and urbanisation. The International Osteo-porosis Foundation (IOF) reports that as of 2012, 9.91 millionpeople in Pakistan have osteoporosis, and this is estimated toincrease to 11.3 million in 2020 and to 12.91 million by 2050.7Despite its common occurrence and availability of advanceddiagnostic and treatment modalities, there is lack of optimumutilisation of resources, investigation and treatment. Definiteepidemiological data in the country is lacking and risk factorssuch as multi-parity, longer life span after menopause, lowdietary calcium intake, vitamin D deficiency, and physical inac-tivity  are  on  a  perpetual  rise.  Different  local  studies  havereported the frequency of osteoporosis from 5.6 to 17.8% inpre-menopausal and 20-49.3% in postmenopausal women.6  Since the diagnosis and treatment of osteoporosis lies at anintersection of multiple clinical specialties (endocrinology, rheu-matology,  orthopedic  surgery,  pathology,  family  medicine,etc.), the management is not methodical, and the disease oftengets overlooked or mismanaged owing to a lack of responsibilityassertion by any medical specialty. There is an acute need totake steps to develop guidelines for diagnosis, treatment andAysha Habib Khan and Manju ChandranJournal  of  the College of  Physicians and Surgeons Pakistan 2021,  Vol.  31(04):  371-372372prevention of osteoporosis, dissemination of the resulting guide-lines to the physicians across the country, and for inclusion ofosteoporosis as a priority in the National Action Plan by theGovernment of Pakistan.The  way  forward  for  Pakistan  is  to  develop  country-specificnational  guidelines using the clinical  standards in the APCOFramework as a benchmark. Implementation of the clinical prac-tice guidelines, thus developed, is expected to enable imple-mentation  of  programmes  for  prevention  and  treatment  ofosteoporotic fractures, fracture liaison services (FLS) for preven-tion of secondary fracture prevention (SFP) and provincial andnational fragility fracture networks. Real epidemiological data,produced through registries, will enable identification of  knowl-edge gaps, and drive multi-sector action focusing on the preven-tive  and  management  aspects  of  osteoporosis  throughoutPakistan.REFERENCESClynes MA, Gregson CL, Bruyère O, Cooper C, Dennison EM.1.Osteosarcopenia:  where  osteoporosis  and  sarcopeniacollide.  Rheumatology  (Oxford)  2020;  60(2):529-37.  doi:10.1093/rheumatology/keaa755.Odén A, McCloskey EV, Kanis JA, Harvey NC, Johansson H.2.Burden  of  high  fracture  probability  worldwide:  secularincreases 2010-2040. Osteoporos Int 2015; 26(9):2243-8.doi: 10.1007/s00198-015-3154-6.Cheung CL, Ang SB, Chadha M, Chow ES, Chung YS, Hew3.FL, et al. An updated hip fracture projection in Asia: TheAsian  federation  of  osteoporosis  societies  study.Osteoporos  Sarcopenia  2018;  4(1):16-21.  doi:  10.1016/j.afos.2018.03.003.Chandran M, Bhadada SK, Ebeling PR, Gilchrist NL, Khan4.AH,  Halbout  P,  et  al.  IQ  driving  QI:  The  asia  pacificconsortium  on  osteoporosis  (APCO):  An  innovative  andcollaborative initiative to improve osteoporosis care in theAsia  Pacific.  Osteoporos  Int   2020;  31(11):2077-81.  doi:10.1007/s00198-020-05495-w.Chandran  M,  Mitchell  PJ,  Amphansap  T,  Bhadada  SK,5.Chadha M, Chan DC, et al. Development of the Asia Pacificconsortium  on  osteoporosis  (APCO)  framework:  Clinicalstandards  of  care  for  the  screening,  diagnosis,  andmanagement  of  osteoporosis  in  the  Asia-Pacific  region.Osteoporos  Int  2021;  DOI:  https://doi.org/10.1007/s00198-020-05742-0.Khan AH, Jafri L, Ahmed S, Noordin S. Osteoporosis and its6.perspective in Pakistan: A review of evidence and issues foraddressing  fragility  fractures.  Ann  Med  Surg   2018;29:19-25. doi: 10.1016/j.amsu.2018.03.019.Mithal A, Kaur P. Osteoporosis in Asia: A call to action. Curr7.Osteoporos Rep 2012; 10(4):245-7. Doi: 10.1007/s11914-012-0114-3.••••••••••

Need for clinical guidelines for management of osteoporosis and way forward for Pakistan

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Need for clinical guidelines for management of osteoporosis and way forward for Pakistan

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