March 13, 2003

There is not enough awareness about osteoporosis in post-menopausal women in Pakistan. As a result almost six million women run the risk of suffering from this silent and deadly brittle bone disease, writes Robin Fernandes

Doctors are renewing efforts to combat osteoporosis, the brittle bone disease that affects the lives of thousands of women and, on a smaller scale, men. The effort is considered crucial as doctors fear that its prevalence is rising among post-menopausal women in the country. Proper treatment at this juncture, they say, would save those at risk and their families in social and financial terms.

There are currently 14 million post-menopausal women in Pakistan. Just under half of all post-menopausal women, or the equivalent of six million women, face the risk of osteoporosis. Few among those are diagnosed or even treated for the disease. Until February 2002, the Partnership Against Osteoporosis (PAO) notes, less than half a million women were diagnosed with the bone-eroding disease. Only one-third of those diagnosed were treated with osteoporosis-specific therapies, according to the Partnership.

Dr Pervez Hashmi, an orthopaedic consultant at the Aga Khan University Hospital, says osteoporosis involves the weakening of all bones in the body. It is a slow process, for peak bone mass alone is attained at the age of 30. “As a person crosses the age of 30, there is a progressive loss of bone mass at the rate of 0.25 percent to one per cent every year,” Dr Hashmi said. Among some post-menopausal women the rate of bone loss per year is between four and eight per cent. The primary cause of post-menopausal osteoporosis in women is estrogen deficiency. However, he points out, that not all women who are post-menopausal suffer from osteoporosis. “There are tens of thousands of women with healthy bones as well,” he added.

Although men aren’t immune to the disease, it is women who are twice as likely to develop osteoporosis, due to hormonal changes associated with menopause. Up to 200 million women worldwide suffer from the disease. Men are spared the brunt as they have greater bone mass than women. In the case of men, Dr Hashmi said, bone loss occurs later and advances more slowly.

Local doctors admit that the disease awareness level is low, even though osteoporosis has a greater socio-economic impact on Pakistani women’s lives than other diseases. “Lack of awareness about the prevalence and diagnosis of osteoporosis, low priority of treating women and compliance have been identified as major issues obstructing the proper tackling of the disease,” the PAO observes.

Within the first two years of menopause, local doctors say, women must try to determine whether they are at risk or not. The first step is to take a bone mineral density test. “Anyone recording a reading below -2.5 needs active treatment (for osteoporosis),” a local orthopaedic surgeon said. Each test costs Rs 2,000. Though these tests are simple and painless, few women are able to diagnose the disease accurately, until a fracture occurs. Another problem is that its symptoms are rarely visible.

According to the Pakistan Council on Osteoporosis, four out of ten women older than 50 will sustain at least one osteoporosis-related fracture in their lifetime. Surveys conducted in the country suggest that the incidence is much higher here than in developed countries. Poor dietary conditions and unhealthy social habits are believed to be responsible for this.

Across the border in India, there are an estimated 75 million people aged 60 years or more who run the risk of developing osteoporosis. Calcium and vitamin D intake is measurably lower in Asia and Africa than in the West.

Clinical studies have shown that a ten per cent decrease in bone from the spine, leads to an approximately 100 per cent increase in fracture risk, and a ten per cent decrease in bone from the hip, leads to an approximately 150 per cent increase in risk of fracture of the hip. Once a patient experiences a fracture, there is an even greater likelihood that other fractures may occur in the near future as the disease progresses.

The ultimate aim should be to build the strength of the bone to normal, in order to decrease the risk of subsequent fractures and their associated morbidity and mortality. A bone mineral density (BMD) test evaluates the quality of bone in the skeleton, based on density. Unfortunately, this test is conducted in just two or three centres in Pakistan.

An X-ray can also be useful, since osteoporotic bones tend to give a different image on the X-ray as compared to normal bones. A risk factor assessment is essential as it reveals the signs and symptoms of osteoporosis. Doctors try to determine whether or not a patient has low bone mass or has suffered from early menopause. Dietary habits, pregnancies and body weight are also key factors.

A few medical therapies have been discovered in recent years, in addition to the conventional dosing of calcium and vitamin D. “A simple intake of calcium or vitamin D alone is not enough, but if the two supplements are taken together there is some effect,” Dr Hashmi said in a presentation this week. Among the osteoporosis-specific therapies, a patented version of Alendronate sodium, has been found to be the most effective, according to the Partnership. Its manufacturer, Merck Sharp & Dome, introduced a novel “once weekly” formulation in Pakistan this month.

According to Dr Hashmi, two other therapies are also available in the country but these are for daily use, like the 10mg version of Fosomax. Obviously, he says, the weekly dose (of Fosomax) is a cost-effective option.

Almost 90 per cent of post-menopausal women with osteoporosis prefer a weekly dosing regimen to a daily one, according to a study carried out in 19 countries. Apart from the dosing preference for the 70mg variety of Merck’s Fosomax, the study measured the convenience and willingness to continue the therapy on a long term. In those areas also the weekly variety of the drug appeared to do well. Fosomax, a worldwide favourite among osteoporosis sufferers, is the only oral medication available for the treatment of post-menopausal osteoporosis.

Osteoporosis is recognized as the disease of the skeleton caused by progressive age-related loss of bone strength that leads to increased risk for fractures in men and women over the age of 40. Over a period of time, the body continuously removes and replaces bone to keep the skeleton strong and healthy. This process, however, begins to shift and more bone is lost than is replaced. A National Osteoporosis Risk Assessment study showed recently that almost half of all post-menopausal women aged 50 and above are at an increased risk of fractures within one year.

 

A celebrity patient Theatre icon and classical dancer Sheema Kermani found out that she had osteoporosis some five years ago. The discovery was made almost by accident. “One day I woke up and I felt my (natural set of) teeth were loose. My dentist told me that there was some bone loss in my jaw-bone,” the 50-year old actress and dancer recalled at a press conference called by the Partnership Against Osteoporosis. A bone mineral density test confirmed the dentist’s suspicions. Until then, Ms Kermani says, she led a very active life. “I wasn’t the same for quite some time,” she confessed. One of her doctors was unusually blunt, and even alarmist by her reckoning. “He told me, even a little sneeze can cause a fracture,” she said, slowly nodding her head. “Of course, I thought I was close to being dead then.” But she somehow summoned up her reserve of inner strength to battle the disease, as well as the melancholy that had begun to set in. “Prescription drugs alone can’t help much. Every person has to discover for themselves the ways and means to combat osteoporosis,” she pointed out. “I resumed my yoga exercises and dance routines, and took to alternative medicines in addition to my daily dose of aledronate sodium,” she said. Tibetan medicines, considered unique because they are prepared in sunlight, were included in her regimen as well. “These are in a sense therapies by themselves.” Ms Kermani claims she knows perhaps as much about osteoporosis as some specialist doctors do. She has read extensively about this silent disease and collected all the available data and information from the Internet and other sources of information. “I learnt that osteoporosis attacks acrobats and dancers at an early age. Eighteen and 20-year-olds are known to be victims,” she remarks. Ms Kermani refers to the disease as the scourge of predominantly Asian and African women. “The reasons are obvious. People from these two regions are suffering from poverty and malnutrition,” she explains. “We must ensure our children drink sufficient quantities of milk. Milk is essential. So is butter,” she says, adding that awareness levels were disappointingly low in this regard. “Dieting, too, can cause some harm to young girls. But this harm does not appear until it is too late.” “Osteoporosis is a silent killer that keeps attacking you. It manifests itself in two ways. In one form it is a slow, natural ageing disease, while the other, far deadlier form is when the bone mass is prematurely reduced in a human,” she observes. Her jaw bone is still the same as before. But, she says, at least she now knows the risk of fracture is reduced, thanks to a medication she takes as part of her daily treatment. Like other consumers of the patented drug, she remains upright for half an hour after taking the pill. For Ms Kermani, fracture risks may have been reduced but fears over the uncertainity of everyday life remain. “I want to do what I want to do. I just don’t know how long I will live...” she sighs. — R.F

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