Epidemiological characterization of patients with osteoporosis in a specialized center in Medellín, Colombia.
https://doi.org/10.46856/grp.10.e197
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Cadavid Roldán C, Ramírez Orozco J, Aristizábal Henao N, Hormaza Ángel M, Vera Marín C, Velásquez-Franco C, Mesa-Navas M. Epidemiological characterization of patients with osteoporosis in a specialized center in Medellín, Colombia. Global Rheumatology. Vol 5/ Jul - Dic [2024]. Available from: https://doi.org/10.46856/grp.10.e197
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Epidemiological characterization of patients with osteoporosis in a specialized center in Medellín, Colombia.
BACKGROUND
In Colombia, in women over 50 years of age, a prevalence of osteoporosis (OP) of 15.7% in the spine and 11. 4% in the proximal femur, however, its local impact is unknown. For this reason, we set out to characterize clinically and socio-demographically the patients with OP who consulted a high complexity hospital in northwestern Colombia from January 2011 to December 2017.
MATERIALS AND METHODS
A descriptive and retrospective study was carried out. Stories of patients over 18 years of age with a diagnostic code of OP were included. The information was collected from medical records and tabulated in an Excel database. Descriptive statistics were applied for the analysis using SPSSv.24 software.
RESULTS
177 patients were included, 91.5% (n=161) female, age 68 ± 11, the main cause of OP was postmenopausal with 78.5% (n=139), followed by secondary causes 19.8% (n=35). The highest proportion of osteoporosis and fractures was represented in the lumbar spine with 71.4%. 60.5% (n=107) of the patients had bone densitometry reported in the medical history, at the time of entering the diagnosis of OP.
CONCLUSIONS
T-scores less than -2.5 were found in the lumbar spine, a significant percentage of secondary causes were found, and less than half of the patients did not have bone densitometry at the time of diagnosis nor were they receiving pharmacological treatment.
Osteoporosis (OP) is a clinical condition characterized by low bone mass and changes in bone microarchitecture that result in a state of bone fragility, leading to an increased risk of fractures associated with significant morbidity, disability, and mortality (1).
According to a meta-analysis of more than 80 studies with a sample of over 100 million patients from all five continents, the estimated global prevalence of osteoporosis was 18.3% (95% CI 16.2–20.7%), with a prevalence of 23.1% in women (95% CI: 19.8–26.9%) and 11.7% in men (95% CI 9.6–14.1%). The analysis also showed that Africa has a higher prevalence compared to the rest of the world; however, the data are limited (4). Additionally, more than 8.9 million fragility fractures occur worldwide each year, and approximately 80% of patients become unable to perform self-care tasks, while 64% require institutional care (2). One in three women and one in five men over the age of 50 will experience an osteoporotic fracture. It is estimated that hip fractures will increase by 310% in men and 240% in women by the year 2050 (3). Among women over 45 years old, OP is responsible for more hospital days than diabetes mellitus, myocardial infarction, or breast cancer (4).
In Colombia, osteoporosis is not considered a public health priority; however, projections show a significant increase in the elderly population, which is at risk of developing this disease.
The direct and indirect costs associated with OP are very high. In Colombia, it was estimated that in 2015, the economic impact of treating hip fractures would exceed 205 million pesos; for vertebral fractures with surgical management, more than 1.3 billion pesos; and for distal radius fractures, over 122 million pesos (5),(6). It has also been estimated that the annual global costs, based on an analysis of Latin American countries such as Mexico, Argentina, Brazil, and Colombia, reached approximately 94 million dollars (7).
According to 2012 projections by the International Osteoporosis Foundation, although data for Latin America were insufficient, estimates suggested that there would be 1,423,559 women with OP in Colombia and between 8,000 to 10,000 hip fractures annually (8).
However, a study compiling information from reports on patients treated for OP from 2012 to 2018, based on data from the Colombian Ministry of Health, reported 249,803 cases—about one-fifth of the estimated total. The same study indicated that the prevalence in men ranged between 2.3 and 206.2 per 100,000 inhabitants, and in women between 12 and 2190 per 100,000 inhabitants. The departments with the highest prevalence were Risaralda, Antioquia, and Caldas, with an overall estimated prevalence of 2.4% in individuals over 50 years of age (9).
Nevertheless, in Colombia, after an extensive literature review, although there is epidemiological information about OP, there is limited data regarding the baseline characteristics of these individuals, their risk factors, densitometric features, and pharmacological treatment.
Given the arguments presented above—the high disease burden and the consequences of OP, along with the lack of local information—this study aimed to conduct a clinical and sociodemographic characterization of patients with OP treated at a medium-complexity care center in Medellín, Colombia.
Design
A descriptive and retrospective study was conducted.
Eligibility criteria
Medical records of patients over 18 years of age with a diagnosis of OP with bone densitometry, presence of fragility fractures, personal history, and pharmacological treatment were included, according to ICD-10 codes: M819, M809, E349, M821, C900, M820, M818, M808, M815, M805, M814, M804, M816, M812, M802, M813, M803, M810, M800, M811, M801, M818, M808, M818, M808.
Sample size calculation
According to information provided by the information management area of the reference institution, a total of 2,213 osteoporosis diagnoses were made between 2011 and 2017; based on a prevalence of 11.7%, a sample size of 149 patients was calculated with an alpha of 0.05 and an expected error of 5%. The calculation was performed using the Epidat program, version 4.2.
Data collection
The information was collected from medical records and tabulated in a Microsoft Excel spreadsheet, version 2019.
Statistical analysis
Descriptive statistics were applied for the analysis using SPSS software v.24.
Variables
Sociodemographic: age, sex, active smoking, physical activity.
Clinical: Concomitant medications related to osteoporosis (aromatase inhibitors, anticonvulsants, and glucocorticoids); type of osteoporosis (postmenopausal or secondary); previous fragility fractures (hip, forearm, vertebral); type of treatment (antiresorptives, denosumab, or anabolic therapy), drug holidays; fractures by anatomical segment; hospitalizations due to fractures.
Radiological: Bone densitometry results (Bone Mineral Density, T-score and Z-score in spine, hip, and forearm).
Ethical considerations
Under current legislation, the study was considered risk-free, as it consisted of a retrospective review of medical records, without specific interventions in patients. The study was approved by the Ethics Committee of the participating institution through record dated April 7, 2018.
Baseline Characteristics
A total of 177 subjects were included. The baseline characteristics are shown in Table 1; there was a predominance of female sex, and postmenopausal osteoporosis was the most common cause of osteoporosis.
Table 1. Clinical characteristics of a cohort of patients with osteoporosis in a referral center in northwestern Colombia
Densitometric Characteristics
A total of 60.5% (n=107) of the patients had a bone densitometry report in their medical records at the time of osteoporosis (OP) diagnosis. In 21 patients (11.8%), the diagnosis was made based on a previous fragility fracture. The remaining patients did have OP, but it was not confirmed by densitometry at the first medical visit when the diagnosis was made.
Of all the densitometry exams, the equipment used was reported in 58.87% (n=63), of which 66.7% (n=42) were LUNAR° and 33.3% (n=21) were HOLOGIC°.
Among patients with an OP diagnosis, bone densitometry, and evaluation of the specific anatomical site, the highest proportion of osteoporosis was found in the lumbar spine with 71.4%. The distribution of densitometric findings is highlighted in Table 2.
Table 2. Frequency of bone densitometry findings in a cohort of patients with osteoporosis from northwestern Colombia
Secondary Causes of Osteoporosis
Out of the entire cohort, 35 subjects had secondary causes; their percentage distribution is illustrated in Table 3. Glucocorticoids represented the highest number of patients (n=10); however, patients could have more than one cause.
A total of 10 patients had multiple causes of secondary OP: two subjects with breast cancer under treatment, two with chronic kidney disease, two with hypogonadotropic hypogonadism and adrenal cancer, and one case each of gastrectomy, autoimmune polyglandular failure, and asymptomatic hypercalciuria.
Table 3. Causes of secondary osteoporosis (n=35)
Fractures
Out of the entire cohort, 55 patients had a fracture; the highest percentage corresponded to vertebral fractures. The distribution of fractures in this cohort is shown in Table 4.
Hospitalizations due to new fractures were reported in 5 out of 177 patients (2.8%).
Table 4. Distribution of fracture types in a cohort of patients with osteoporosis from northwestern Colombia
Pharmacological Treatment
At the time of the first visit, 46.9% (n=83) of the patients were receiving bisphosphonates, with the most commonly used being alendronate (51.8%, n=43) and zoledronic acid (36.14%, n=30); other bisphosphonates such as ibandronate and risedronate were used less frequently: 9.63% (n=8) and 2.40% (n=2), respectively. The median duration of bisphosphonate use was 12 months (range 5–45).
Teriparatide was used in 19 individuals (10.73%), with a median use of 11.9 months. In the cohort, 17 subjects received denosumab (9.6%), with a median use of 12 months (range 6–18). Bone holidays were reported in only 1.1% of patients (n=2).
In our cohort of patients with osteoporosis (OP) at a referral hospital in northwestern Colombia, significant findings included a T‑score below –2.5 in the lumbar spine, a substantial proportion of secondary causes, and fewer than half of the patients had bone densitometry at the time of diagnosis or were receiving pharmacological treatment.
Regarding the secondary causes of OP reported in our study, the prevalence was notably high. This may be explained by the predominance of elderly patients and the fact that the center is a reference in endocrinology and rheumatology. However, it contrasts with another Colombian study in which the secondary causes in postmenopausal women were vitamin D deficiency (71.8%), hyperparathyroidism (18.1%), and hypercalciuria (6.4%) (10). Another Colombian cohort of only male patients showed that 61% had secondary osteoporosis, with the primary causes being chronic glucocorticoid use (42.1%), hypogonadism (23.7%), and hyperparathyroidism (16.4%) (11). In our cohort, glucocorticoid use and hyperparathyroidism predominated.
Concerning baseline characteristics, a low percentage of active smoking and physical activity was observed. These findings are similar to those of a study in the city of Santa Marta, where only 5% reported smoking (12), likely due to underreporting in clinical records. However, in Manizales, smoking was identified in 58.2% and alcohol use in 10% of subjects (11). An Argentine cohort showed that 23.9% of OP patients smoked; unlike ours, that cohort included only secondary OP cases (13).
Diagnosis by bone densitometry, according to a global meta-analysis, was performed in 19.6% of cases (95% CI, 14.3–26.2) from a sample of over 100 million individuals (14). Moreover, a 2018 study in Bogotá reported a densitometry reporting rate of 54.3%, similar to our study, of which 47% had OP and 8% had osteopenia (9).
In Medellín, Hormaza and colleagues demonstrated that women over 50 had an OP prevalence of 15.7% in the spine and 11.4% in the proximal femur. Osteopenia was present in the spine and proximal femur in 49.7% and 47.5%, respectively. The lowest concentrations of 25‑hydroxyvitamin D were found in women with low bone mass or osteopenia, with a median of 17 ng/mL (range 13.0–20.4 ng/mL) (15). In our cohort, this deficiency accounted for 3% of secondary causes, potentially due to inadequate documentation. Another study in Cali, Colombia, reported 55.3% 25(OH)D insufficiency among OP patients (16). In Ecuador, 58% had a diagnosis of OP (mean age 67 years) and 42% had osteopenia. Among those with 25(OH)D levels below 30 ng/mL, 42.9% were deficient (17).
In Cuba, 58% of individuals had poor bone quality (osteopenia or OP), and 16.8% had OP (18). In Mexico, OP prevalence was 13.9% (19). In Argentina, of 1,021 patients, 18.7% had OP in the lumbar spine and femoral neck (20). In China, among people over 50, OP prevalence rose from 14.8% before 2008 to 27.96% between 2012–2015, and was higher in rural areas compared to urban (20.87% vs. 23.92%) (21). In Colombian women, an estimated 8,000–10,000 hip fractures occur annually, 90% treated surgically, with 284,711 vertebral fractures per year (8). In our cohort of 55 patients with fractures, 15.8% were vertebral, followed by distal radius and unilateral hip at 3.3%. This aligns with our finding of dominant lumbar spine OP. The Latin American Vertebral Osteoporosis Study (LAVOS) showed a similar rate of radiographically defined vertebral fractures in Colombia compared to other countries: overall 11.7% among women aged 50–79; in Colombia, 22% of women aged 70–79 had radiographic vertebral fractures, with an overall fracture prevalence of 10.72% and asymptomatic fractures in 7.3% (7).
In Bogotá, Medina and colleagues found in a retrospective study of 184 subjects that the most frequent fragility fracture sites were distal radius (36%) and vertebrae; 30% had OP, and only 30% received complete treatment before fracture and 57.6% afterward (9). Another Colombian study of adults with primary hip fracture (66.7% women) found OP in 4.2% (22). A study in Manizales limited to men showed 42.2% had fragility fractures; 51.4% had a single fracture and 48.6% had two or more. The most common site was the spine (80%), followed by the hip (8.6%) (11). Internationally, studies in postmenopausal women have shown 46% have at least one vertebral fracture; OP prevalence ranged from 31% in women aged 50–55 to 69% in women 65 or older (23).
A Colombian Ministry of Health–based study reported 18% of patients with fractures and OP but could not specify fracture location (24).
In our study, at the first visit, 46.9% (n=83) of patients were already receiving bisphosphonates; alendronate (51.8%, n=43) and zoledronic acid (36.14%, n=30) were most used. Teriparatide was used in 19 patients (10.73%) and denosumab in 9.6%. In a study of male patients in first endocrinology consultations, 100% were prescribed anti-osteoporotic drugs; alendronate was most common (50.2%). Supplements were prescribed in 97.6%, most commonly calcium plus vitamin D (90.5%) (11). In a Uruguayan cohort, only 15.22% knew their diagnosis; 69.88% had no treatment prescription; 23.49% received calcium supplements alone or combined; 20.48% used vitamin D; and 4.82% used bisphosphonates. Only five patients had complete treatment (antiresorptive + calcium + vitamin D). Fragility fracture history was present in 26.09%, and 4.82% had more than one previous fracture (25). In an Argentine study 95% received bisphosphonate treatment after OP diagnosis; among osteopenic patients, 43% received antiresorptive treatment (13). In a five‑year follow‑up of 110 men aged 53–99 hospitalized for atraumatic hip fracture, only 4.5% received OP treatment at hospital discharge, and during follow‑up only 27% received any OP treatment; 67% received only calcium and vitamin D (26). In a cohort from Valencia, Spain, 27.7% of women and 3.5% of men took calcium and/or vitamin D supplements, and 28.2% of women (22.0% aged 50–64) and 2.3% of men used anti‑osteoporotics (27). Similarly, a Spanish study of over 2,500 hip fracture patients showed that only 38% received any osteoporotic treatment (28). A systematic review found post‑hip‑fracture treatment rates worldwide ranging from 6% to 61.7% (29). Among Australian postmenopausal women, 29% reported at least one minor trauma fracture after menopause; less than one‑third were on specific OP treatment (30). All of these data underscore that initiation of treatment and awareness of this condition remain global challenges.
In a cohort of Colombian patients with osteoporosis, a T-score defining the disease was most frequently found in the lumbar spine.
One fifth of these subjects had secondary causes of osteoporosis (mainly associated with glucocorticoids) and presented with fractures; less than half of the individuals did not have bone densitometry at the time of diagnosis and were not receiving pharmacological treatment.
The authors declare no conflicts of interest in conducting the study.
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