1. 2010 Guidelines 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada Papaioannou A, et al. CMAJ 2010 Oct 12. [Epub ahead of print].

2. 2010 Guidelines Fragility Fractures and Care Gaps 2010 Guidelines Section Two

3. 2010 Guidelines Fragility Fracture: Definition A fracture occurring spontaneously or following minor trauma such as a fall from standing height or less 1,2 –Excluding craniofacial, hand, ankle and foot fractures 1.Kanis JA, et al. Osteoporos Int 2001; 12(5):417-427. 2.Bessette L, et al. Osteoporos Int 2008; 19:79-86.

4. 2010 Guidelines The Majority of Fractures in Canadian Women > Age 50 Are Fragility Fractures Bessette L, et al. Osteoporos Int 2008; 19:79-86. % of all fractures that are fragility fractures 75.7% 91.8% Overall: 81% 95% 90% 85% 80% 75% 70% 65% 60% 50-5960-6970-7980+ Age groups

5. 2010 Guidelines Consequences of Fracture Increased risk of –Hospitalization/institutionalization 1,2 –Death 3-5Death –Subsequent fracture 6-8Subsequent fracture Decreased quality of life 9-12 Economic burden on healthcare system 2Economic burden on healthcare system 1. Papaioannou A, et al. Osteoporos Int 2001; 12(10):870-874. 2. Wiktorowicz ME, et al. Osteoporos Int 2001; 12(4):271-278. 3. Ioannidis G, et al. CMAJ 2009; 181(5):265-271. 4. Papaioannou A, et al. J SOGC 2000; 22(8):591-597. 5. Tosteson AN, et al. Osteoporos Int 2007; 18(11):1463-1472. 6. Papaioannou A, et al. J SOGC 2000; 22(8):591-597. 7. Colon-Emeric C, et al. Osteoporos Int 2003; 14:879-893. 8. Lindsay R, et al. JAMA 2001; 285:320-323. 9. Sawka AM, et al. Osteoporos Int 2005; 16:1836-1840. 10. Cranney A, et al. J Rheumatol 2005; 32(12):2393-2399. 11. Pasco JA, et al. Osteoporos Int 2005; 16(12):2046-2052. 12. Papaioannou A, et al. Osteoporos Int 2009; 20(5):703-715.

6. 2010 Guidelines Impact on Function and Quality of Life Loss of confidence and fear of falling have been reported with all types of fractures < 40% of those who experience a hip fracture return to their prior walking abilities 1,2 Clinical fractures negatively affect self-care and mobility, and are associated with chronic pain 3Clinical fractures negatively affect self-care and mobility, and are associated with chronic pain 1. Cranney A, et al. J Rheumatol 2005; 32(12):2393-2399. 2. Pasco JA, et al. Osteoporos Int 2005; 16(12):2046-2052. 3. Papaioannou A, et al. Osteoporos Int 2009; 20(5):703-715.

7. 2010 Guidelines Undertreatment of Osteoporosis Post Fracture in Women 1 1. Bessette L, et al. Osteoporos Int 2008; 19:79-86. 2. Papaioannou A, et al. Osteoporos Int 2008; 19(4):581-587. 3. Giangregorio L, Osteoporos Int 2009; 20(9):1471-8. 4. Austin PC, et al. CMAJ 2008; 179(9):901-908. This care gap is even wider in men and those who reside in long-term care 2,3in men A fracture is to osteoporosis what a heart attack is to cardiovascular disease. BUT... The treatment gap is far wider post fracture than post MI. 1,4The treatment gap is far wider post fracture than post MI

8. 2010 Guidelines Looking Beyond BMD Currently, low BMD is the primary trigger for initiation of therapy 1-5... HOWEVER, Most fragility fractures occur in those with a BMD in the non-osteoporotic range (T-score higher than -2.5) 6Most fragility fractures occur in those with a BMD in the non-osteoporotic range There is a missed opportunity to prevent future fractures due to over-reliance on BMD. 6,7 1. Bessette L, et al. Osteoporos Int 2008; 19:79-86. 2. Papaioannou A, et al. BMC Musculoskelet Disord 2004; 5:11. 3. Elliot-Gibson V, et al. Osteoporos Int 2004; 15:767-778. 4. Papaioannou A, et al. Osteoporos Int 2008; 19(4):581-587. 5. Cranney A, et al. Osteoporos Int 2009; 20(9):1621-1625. 6. Cranney A, et al. CMAJ 2007; 177(6):575-580. 7. Langsetmo L, et al. J Bone Miner Res 2009; 24(9):1515-1522.

9. 2010 Guidelines Back-up Material Additional slides that can be accessed by hyperlinks on core slides Section Two – Fragility Fractures and Care Gaps

10. 2010 Guidelines Fracture is a Predictor of Future Fractures The risk of experiencing another fracture in the year following a hip fracture*: 5% – 10% 1,2 The risk of experiencing another vertebral fracture in the year following a vertebral fracture † : 20% 3 Prevalent vertebral fractures also predict hip fracture* 4,5 40% of Canadians who experience a fracture have a history of prior fracture 6 1. Papaioannou A, et al. JOGC 2000; 22(8):591-597. 2. Colon-Emeric C, et al. Osteoporos Int 2003; 14:879-893. 3. Lindsay R, et al. JAMA 2001; 285:320-323. 4. Ismail AA, et al. Osteoporos Int 2001; 12(2):85-90. 5. Melton LJ 3rd, et al. Osteoporos Int 1999; 10(3):214-21. 6. Hajcsar EE, et al. CMAJ 2000, 163:819-822. Return to main presentation * in men and women † in postmenopausal women

11. 2010 Guidelines One-year Mortality Risk after Hip Fracture 12 1. Ioannidis G, et al. CMAJ 2009; 181(5):265-271. 2. Papaioannou A, et al. J SOGC 2000; 22(8):591-597.

12. 2010 Guidelines Increased Mortality Risk after Vertebral Fracture 1 2 Ioannidis G, et al. CMAJ 2009; 181(5):265-271. Return to main presentation

13. 2010 Guidelines HUI3 Deficits Associated with Fractures in Women, by Fracture Type Return to main presentation Papaioannou A, et al. Osteoporos Int 2009; 20(5):703-14. Multi (HUI2) 0 -0.05 -0.1 -0.15 -0.2 -0.25 Mobility (HUI2) Pain (HUI2) Self-care (HUI2) Multi (HUI3) Ambulation (HUI3) Pain (HUI3) OtherRibSpineHip

14. 2010 Guidelines Increasing Costs Associated with Hip Fracture ($CDN) Return to main presentation Wiktorowicz ME, et al. Osteoporos Int 2001; 12(4):271-278.

15. 2010 Guidelines Therapeutic Care Gap: Most Men Do Not Receive Treatment for Osteoporosis after Fracture Return to main presentation Papaioannou A, et al. Osteoporos Int 2008; 19(4):581-587.

16. 2010 Guidelines Post-fracture Care Gap: Comparison with Heart Attack 1. Bessette L, et al. Osteoporos Int 2008; 19:79-86. 2. Austin PC, et al. CMAJ 2008; 179(9):901-908. Return to main presentation

17. 2010 Guidelines No. of fractures 0 100 200 300 400 500 Most Fragility Fractures in Postmenopausal Women Occur with Low Bone Mass ("Osteopenia") Return to main presentation Cranney A, et al. CMAJ 2007; 177(6):575-580. > 0.00.0 to -0.5 -0.5 to -1.0 -1.0 to -1.5 -1.5 to -2.0 -2.0 to -2.5 -2.5 to -3.0 -3.0 to -3.5 ≤ -3.5 NormalOsteo- penia Osteo- porosis WHO categoryT-score 60 50 40 30 20 10 0 Fracture rate Fracture rate, per 1000 person-years There is a missed opportunity to prevent fractures due to over-reliance on BMD.