Clin Calcium 2004 Sept 14(9):100-5. Management of Osteoporosis: The Indian perspective
Rohini Handa MD, DNB, FAMS, FICP, FACR Professor of Medicine Clinical Immunology & Rheumatology Service Secretary General, Osteoporosis Society of India All India Institute of Medical Sciences New Delhi, India Email:
[email protected]
Abstract Osteoporosis is a common but neglected problem in India. The major challenges to management are lack of awareness and resource constraints. The management is also hampered by the non-availability of normative data for bone mineral density in Indians. Subclinical vitamin D deficiency is widespread. The drugs available in the country include calcium, vitamin D, hormone replacement therapy,
raloxifene, alendronate,
risedronate, calcitonin and teriparatide. Bisphosphonates (alendronate) constitute the mainstay of treatment in India. There is a need for evidence based, context specific and resource sensitive guidelines.
Introduction The scourge of osteoporosis knows no boundaries. It is a global disease and India is no exception. No community based prevalence statistics are available. However, estimates by expert groups like the Osteoporosis Society of India peg the number of osteoporosis patients in India at 26 million approximately (2003 figures), with the numbers projected to increase to 36 million by 20131). India is truly in the throes of an osteoporosis epidemic that, unfortunately, has attracted little attention and even less action.
Challenges in the management of osteoporosis in India Given India’s size and population, the logistics and economics of osteoporosis as well as its prevention and control need to be considered in a realistic manner. However, public and physician awareness about the disease and its impact continue to be low in the country2, 3, 4). Several factors are responsible for this neglect (Figure 1): 1. The long held belief that osteoporosis is a disease of the west and does not exist in India. 2. The notion that osteoporosis is an inevitable consequence of ageing which can neither be treated nor prevented. 3. Preoccupation of the health planners with infectious diseases 4. Limited availability of diagnostic facilities 5. Paucity of epidemiologic data
The low life expectancy at birth, a few decades ago, meant that earlier most Indians did not live long enough to develop osteoporosis. Osteoporosis was thought to be an exotic disease, seldom suspected, rarely diagnosed. With ageing of the Indian population this has changed. The number of people older than 60 now number 82 million (2002 figures). The awareness about the disease is low with many physicians subscribing to the nihilistic view that ‘nothing can be done, nothing needs to be done’ for osteoporosis. Traditionally, infectious diseases have occupied the centre stage in the Indian health scenario. Tuberculosis, malaria, leishmaniasis and HIV continue to be formidable foes. Of the noncommunicable diseases, cardiovascular diseases are perceived as perhaps the most
important. These so called ‘glamorous’ non-communicable diseases have relegated bone health to the background. India, being a male dominated society, also has to contend with the fact that women’s health is not a priority issue. Dual energy x-ray absorptiometry (DEXA) machines are available in only a handful of urban centers, mostly privately owned. Few government hospitals have the facilities for estimation of bone density. Biochemical markers are not yet freely available in India. Though only a small percentage of urban Indians go for medical insurance, it is of interest to note that insurance companies pay for hospitalization and treatment of fracture alone. DEXA scans and domiciliary treatment for osteoporosis are not reimbursable in India. Another factor, important in the Indian scenario, is the domination of osteoporosis field by orthopedic surgeons whose emphasis is on treatment of fracture. Detection and treatment before the occurrence of first fracture is uncommon.
Management issues unique to India The management of osteoporosis in India poses some unique problems: early onset of osteoporosis, absence of normative BMD data, wide spread sub clinical vitamin D deficiency in the country, tuberculosis as a confounder, and the need for identification of calcium rich items in Indian diet. Osteoporosis begins at an early age in India and affects more males Several studies5~8) have shown that osteoporotic fractures usually occur 10-20 years earlier in Indians compared to Caucasians. Some of these studies were done nearly 40 years ago, and none have used DEXA to confirm osteoporosis. One hypothesis that has been advanced to explain the early onset is that a dietary deficiency of calcium, beginning early in life, leads to a lower peak bone mass and consequently osteoporosis at an earlier age in Indians9). Another contributory factor could be subclinical vitamin D deficiency causing malabsorption of calcium without overt osteomalacia9). However, this hypothesis needs validation in rigorously designed studies. Another interesting observation has been the high proportion of male patients among hip fracture cases in India5~8 which is contrary to what is seen in other areas. Lower hospital attendance and health service utilization by women in India, especially the elderly, may be the main reason behind the skewing of data.
Bone mineral density: Can Caucasian data be applied to Indians? The reference data provided by the DEXA manufacturers are derived from Caucasian postmenopausal women. In absence of normative data from other races, these criteria have been widely accepted and used in clinical practice. Emerging data reveal that these criteria may not be applicable to Indians10, 11). Tandon et al studied studied 40 men and 50 women, 20-30 years of age, from the Indian paramilitary forces. These individuals consume a nutritious, high-protein diet, have optimal exposure to sunlight and undertake strenuous outdoor physical exercise. These healthy young individuals were found to have normal bone and mineral biochemical values. However, bone mineral density estimated in 20 men and 22 women revealed that in comparison with white Caucasians, 35%-50% of men and 14%-32% of women were osteopenic at different sites, while an additional 10% of men had osteoporosis of the lumbar spine11). Thus, there is a need for establishing normative BMD data for Indians. It is likely that the existing reference norms may lead to over diagnosis of osteopenia/osteoporosis in a substantial number of Indian patients. Coexistence of Vitamin D deficiency India, located between 8.4 degrees N and 37.6 degrees N latitudes, gets plenty of sunshine through out the year and it is generally presumed that Indians are vitamin D sufficient. Arya and colleagues12) measured serum 25-hydroxy vitamin D [25(OH)D] (n=92) and 1,25-dihydroxy vitamin D [1, 25(OH)2D] ( n=65) levels in healthy hospital staff. Using a serum 25(OH)D level of 15 ng/ml as a cutoff, 66.3% of the subjects were found to be vitamin D deficient. Of these, 20.6% subjects had severe vitamin D deficiency (
