1. CHOICE OF TREATMENTS OF OSTEOPOROSIS IN VIETNAM Le Anh Thu, MD, PhD Department of Rheumatology Cho Ray Hospital, Vietnam

2. CONTENTS Magnitude of the problem Current guidelines Therapies available Economic consideration Summary

3. Osteoporosis and Fracture  Prevalence of osteoporosis in Vietnam (postmenopausal women): 23% or 2.5 million (Huong Nguyen, et al, Osteoporosis Int 2008)  Lifetime risk of fractures in Vietnam: unknown  Lifetime risk of fractures in Caucasian women: 44% (Nguyen ND, et al, JBMR 2007)

4. Prevalence of Osteoporosis CountryPrevalence of osteoporosis (T-scores < -2.5) Vietnam23.1 Thailand29.5 Indonesia~15.0 Hong Kong49.6 China10.1 Japan17.0 South Korea~10.0 Australia21.4 U.S.A (White)20.0

5. Incidence of Hip Fractures Nguồn: EMC Lau, et al. Osteoporosis Int 2001;12:239-43 USA Hong Kong Singapore Thailand

6. 104 PopulationPopulation age + 65 The Aging of Population –Population: 84 million (2008) -- 104 million (2030) –Population over 65: 7% (2008) -- 11% (2030)

7. Projected Number of Fractures in Vietnam 2006-2030

8. Projected Number of Hip Fractures in Vietnam 2006-2030

9. Treatment Guidelines – Asian Osteoporosis Foundation

10. Source : World Bank Development Indicators 2007 Vietnam (~700 USD) Per Capita GDP (2007)

11. Fosamax Rocaltrol Miacalcic spray (200 IU) Miacalcic spray (50 IU) Evista Glakay BRIOZCAL (calcium) Strontium Ranelate (in near future) Zoledronate (in near future) Therapies Available in Vietnam

12. Osteoporosis Therapies and GDP FormulationCompany Price per tab/cap (in USD) Daily cost (USD) Yearly cost (USD)/ average income FOSAMAX Tab 70mgMSD5.36 0.77 280 (40%) ROCALTROLTab 0.25mcgROCHE 0.21 0.43 157 (22.4%) MIACALCIC Spray 200 IUNasal sprayNOVARTIS 71.22 5.09 1,825 (260%) MIACALCIC Inj.- 50IUAmpoulesNOVARTIS 4.41 8.82 3,220 (460%) EVISTATab 60mgELI LILY0.875 320 (45.7%) GLAKAYCapsule 15mgEISAI0.361.07 390 (55.7%) BRIOZCAL Tab 500mg + 800 UI D3BHC0.170.34 124 (17.8%) MILK500ML 0.62 228 (32.5%)

13. Public health insurance system covers <50% of treatment costs Osteoporosis treatment: Health insurance covers Alendronate (only in tertiary hospitals, from 7/2008) Health Insurance

14. Cost-effectiveness of Treatment 2.5 million osteoporosis Number of hip fractures: 25,000 (incidence 1%) Cost of Rx: 60 million USD (2.500/case) Number of hip fractures: 12,500 (RR=0.5) Treatment Cost: 1.01 billion (404 USD/year) Cost to reduce one hip fracture case: 80.800 USD

15. Number Needed to Treat (NNT) and Baseline Risk Data were obtained from published RCTs in osteoporosis and antifracture efficacy

16. Optimal Strategy for Treatment and Prevention Treatment Identify individuals at high-risk of fracture; Select therapies that are efficacious and safe Prevention Increase community awareness and knowledge of osteoporosis Encouragement of healthy lifestyles

17. Idenfication of High-risk Individuals Use of risk factors Age, low BMD, prior fracture, corticosteroid use, fall, cigarette smoking, low body weight, etc. Use current algorithms of absolute risk FRAX model Garvan Institute’s model

18. Selection of Efficacious and Safe Therapies Evidence-based medicine Meta-analysis of RCTs RCT (randomized controlled clinical trials) Well designed prospective studies Cost consideration Affordable

19. Challenges in Treatment and Management of Osteoporosis in Vietnam Osteoporosis and fracture are increasingly prevalent in Vietnam. Effective therapies are available Per capita GDP is low. Cost of treatment could take up to 40% of per capita GDP. However, treatment seems worthwhile for high- risk individuals.

20. Acknowledgments On behalf of the Osteoporosis Society of Ho Chi Minh City, I would like to acknowledge the support and help of: Bridge Healthcare, Eisai, MSD (Vietnam), Norvatis, Servier…. Prof Tuan Nguyen of the Garvan Institute of Medical Research for helpful suggestions and critical comments All members in Organization Committee

21. World Osteoporosis Day in HoChiMinh City on October 20 each year.

22. Promotion for bone health in community

23. Some preliminary efforts

24. Established Osteoporosis Association of HCM City 12 August 2006

25. Strong Bone Asian in Pattaya, Thailand September 2007