estimation of osteoporosis risk among women attending ... - wjpps

2 downloads 0 Views 1MB Size Report
Apr 5, 2014 - Vamsi Krishna.B¹*, Seeba Zachariah², Dr.Mohanraj Rathinevelu²,. Dr. Y. Padmanabha Reddy ³. ¹Intern,Doctor of pharmacy, Raghavendra ...
WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES Vamsi et al.

World Journal of Pharmacy and Pharmaceutical Sciences

Volume 3, Issue 5, 1032-1043.

Research Article

ISSN 2278 – 4357

ESTIMATION OF OSTEOPOROSIS RISK AMONG WOMEN ATTENDING ORTHOPAEDIC CLINICS IN SOUTH INDIA Vamsi Krishna.B¹*, Seeba Zachariah², Dr.Mohanraj Rathinevelu², Dr. Y. Padmanabha Reddy ³ ¹Intern,Doctor of pharmacy, Raghavendra Institute of Pharmaceutical Education & Research, Ananatapuramu, Andhra Pradesh, India – 515721. ²Assistant Professor, Department of Pharmacy practice, Raghavendra Institute of Pharmaceutical Education & Research, Ananatapuramu, Andhra Pradesh, India – 515721. ³Professor & Principal, Raghavendra Institute of Pharmaceutical Education & Research, Ananatapuramu, Andhra Pradesh, India – 515721

Article Received on 10 March 2014, Revised on 05 April 2014, Accepted on 26 April 2014

ABSTRACT The Study entitled “Estimation of osteoporosis risk among women attending orthopaedic clinics in South India was designed to estimate the risk of osteoporosis in women, assessment of adherence and awareness on treatment of hip fracture patients & to counsel the

*Correspondence for Author

patients for improving the health outcomes. The prospective

Vamsi Krishna.B

observational epidemiological study for six months duration was

Assistant Professor,

carried out in women over 45 years of age. Discussion on risk

Department of Pharmacy

estimation for osteoporosis through SCORE questionnaire was done in

practice, Raghavendra Institute of Pharmaceutical Education &

patients visiting orthopaedic clinics in Anantapur, Andhrapradesh.

Research, Anantapuramu,

From the score of risk estimation questionnaire for all the patients

Andhra Pradesh, India-515721

(500) it was found that females are at more risk for developing osteoporosis with increasing age and statistically significant P-value

(0.0429) was found between age groups 65-69 years. Among the study populations 56% of the patients were having R.A and 27% of the patients had broken bones. 56.3% of the female with increasing age were having risk for developing osteoporosis. This can be attributed to the factors like poor knowledge regarding disease, life style modifications, fall reduction and medication adherence. Failure to receive estrogen therapy due to low socio-economic status is the other confounding factor for developing osteoporosis. In conclusion, improving patient’s knowledge through counseling regarding disease and medication adherence can

www.wjpps.com

Vol 3, Issue 5, 2014.

1032

Vamsi et al.

World Journal of Pharmacy and Pharmaceutical Sciences

significantly decrease the risk for osteoporosis. Improvement in medication adherence was found in 80% of the inpatients after counseling. Key words: Risk for osteoporosis, SCORE, Questionnaire, Estrogen therapy. INTRODUCTION Definition Osteoporosis is a disease characterized by – low bone mass, microstructure deterioration of bone tissue, leading to enhanced bone fragility and consequent increase in fracture risk. The word osteoporosis literally means "porous bones." It occurs when bones lose an excessive amount of their protein and mineral content, particularly calcium. Over time, bone mass, and therefore bone strength, is decreased. [1] Etiology Because the patterns of reforming and resorping bone often vary from patient to patient, doctors believe several different factors account for this problem. Important chemicals (such as estrogen, testosterone, parathyroid hormone, and vitamin D) and blood factors that affect cell growth are involved with this process. Changes in levels of any of these factors can play a role in the development of osteoporosis. [1] Role of sex hormones in bone breakdown Sex hormones play a role in osteoporosis in both genders, most likely by controlling the birth and duration of life of both osteoclasts (bone breakers) and osteoblasts (bone builders). A woman experiences a rapid decline in bone density after menopause, when the ovaries stop producing estrogen.

[1]

Estradiol deficiency appears to be a very strong factor in the

development of osteoporosis. After menopause, some amounts of estrogen continue to be manufactured in the adrenals and in peripheral body fat. Even though the adrenals and ovaries have stopped producing estrogens directly, they continue to be a source of the male hormone testosterone, which converts into estradiol. Estrogen may have an impact on bone density in various ways, including preventing bone breakdown. [1] Vitamin D and Parathyroid hormone imbalances Low levels of vitamin D and high levels of parathyroid hormone (PTH) are associated with hip fracture in women after menopause. Vitamin D is essential for the absorption of calcium from the intestines and for normal bone growth. Lower levels result in impaired calcium absorption, which in turn causes an increase in PTH. Parathyroid hormone (PTH) is the most

www.wjpps.com

Vol 3, Issue 5, 2014.

1033

Vamsi et al.

World Journal of Pharmacy and Pharmaceutical Sciences

important regulators of calcium levels in the blood. When calcium levels are low, the glands secrete more PTH, which then increases blood calcium levels. High persistent levels of PTH stimulate bone resorption. [2] Genetics Several studies on family members, including twins, have strongly suggested that genetic factors help determine bone density. [3] Secondary factors of osteoporosis Some medications interfere with calcium absorption or bone formation and can leave us susceptible to developing osteoporosis .They include: steroids or corticosteroids, thyroid medication, antacids with aluminium, proton pump inhibitors (PPIs), antibiotics, anticonvulsants, diuretics , heparin and warfarin, lithium, chemotherapy and methotrexate. Medical conditions Osteoporosis can be secondary to several other conditions, including alcoholism, diabetes, hyperthyroidism, epilepsy, chronic liver or kidney disease, celiac disease, rheumatoid arthritis,

leukaemia,

gastrointestinal

diseases,

vitamin

D

deficiency,

lymphoma,

hyperparathyroidism, and rare genetic disorders like Marfan and Ehlers-Danlos syndrome. [1] Complications Bone density loss from osteoporosis is a major cause of disability and death in the elderly, mostly due to subsequent fractures. The lifetime risk of spinal fracture in women is about one in three, and that for hip fracture is one in six. Women at highest risk for fractures are those with low bone density plus a history of fractures, particularly nonviolent fractures. Osteoporosis and bone fractures Osteoporosis causes more than 1.5 million fractures annually. About 50% of women and 25% of men over age 50 will suffer an osteoporosis-related fracture during their lifetime. Each year, there are about 700,000 spinal fractures, 300,000 hip fractures, 250,000 broken wrists and more than 300,000 fractures of other bones. About 80% of these fractures occur after relatively minor falls or accidents. Unfortunately, studies continue to report inadequate treatment after a fracture. Few patients with sustained fractures are tested or treated for osteoporosis. It is in this regard that the

www.wjpps.com

Vol 3, Issue 5, 2014.

1034

Vamsi et al.

World Journal of Pharmacy and Pharmaceutical Sciences

present study was setup to estimate the osteoporosis risk among women attending orthopaedic clinics in Anantapuramu, Andhrapradesh. MATERIALS AND METHODS Study design: Prospective observational epidemiological study in women > 45 years of age. Study site: The study was conducted in the out-patients and in-patients (for hip fracture) who were attending to R.D.T Hospital Bathalapalli, Vathsalya orthopaedic clinic, Government general hospital Anantapur. Study period: The study was conducted for a period of 6 months from Aug 2012 - Jan2013. Study population: 500 patients. Inclusion criteria: Patients attending orthopaedic clinics and diagnosed with osteoporosis and patients who are having hip fracture. Exclusion criteria: Patients above 90 years of age & Patients below 40 years of age. Study procedure: Patient enrolment: Patient satisfying the inclusion criteria, who expressed an interest in participating in the study were enrolled after the nature of the study was explained to them and their informed consent was obtained. Collection of data Patient details were collected through the suitably designed data collection form and by patient’s interview, prescriptions. Patient details are collected with the help of SCORE screening scale. Criteria The criteria for SCORE screening scale are as follows: Age: Age below 65 is considered as 0 & Age above 65 – calculate 3 × (1st digit in age) Race: 5 points (not black) Fracture: 4 points per fracture Rheumatoid arthritis: If yes 4 points Estrogen Therapy: If yes 0 If No 1 Weight: Calculate (-1×weight in pounds)/10 By following the above criteria the patient details were documented. Statistical methods: p-values calculation. Statistical tool used was GraphPad Instat (v 3.10)

www.wjpps.com

Vol 3, Issue 5, 2014.

1035

Vamsi et al.

World Journal of Pharmacy and Pharmaceutical Sciences

RESULTS SCORE screening for osteoporosis The current study carried out score screening for 500 patients attending orthopaedic O.P.D. We collected their data with the help of a SCORE screening scale. Demographic details of the participants involved in the study were categorized based on age distribution, the results of which were thoroughly analyzed and reported in Fig. 1.

n = 500

Age Percentage

80.00% 60.00%

65.60% 28%

40.00%

5.6 %

20.00%

0.80%

0.00% Age below 65 Age 65 - 69

Age 70 - 79 Age above 80

Age

Fig. 1. Age Distribution of the participants Final scores of the patients: The final score of the 149 patients who are having a score greater than or equal to 6 is reported in Table. 1. Table. 1. Final score Final score ≥6 - 10 11 - 20 Above 20

No. of Patients 2 128 18

Percentage 1.34% 85.40% 12.8%

The SCORE values in study population are reported in Fig. 2. n = 149

Percentage

100.00%

85.40 %

80.00% 60.00% 40.00%

12.8 0%

20.00%

1.34 %

SCORE

0.00% score above 20 scoreabove 10 Score score 10 & less than 10

Fig. 2. SCORE values in study population www.wjpps.com

Vol 3, Issue 5, 2014.

1036

Vamsi et al.

World Journal of Pharmacy and Pharmaceutical Sciences

Out of 500 patients 56% people had rheumatoid arthritis. 27% of the patients had history of broken bones the results of which are reported in Table. 2. Table. 2. % of patients with Rheumatoid Arthritis and broken bones Complication R.A Broken Bones

Number 280 135

Percentage 56% 27%

Patients having or being treated with Rheumatoid Arthritis & History of broken bones is reported in Fig. 3. n = 500 Percentage

80% 60% 40%

With

20%

Without

0% R.A

Broken bones Complication

Fig. 3. Distribution of RA & History of broken bones in study population Common points between study population who are having Positive and Negative final score values is reported in Fig. 4. as Total SCORE distribution of the patients. n = 500

25 20 15 score

10 5

SCORE

-5

1 41 81 121 161 201 241 281 321 361 401 441 481

0 -10 -15

Number

Fig. 4.Score values in the study population

www.wjpps.com

Vol 3, Issue 5, 2014.

1037

Vamsi et al.

World Journal of Pharmacy and Pharmaceutical Sciences

In our study, out of 500 study population 268 people are having a score below Zero i.e., Negative value. They account for about 53.6% of the study population. 232 people are having a score above Zero i.e., Positive value. They account about 46.4% of the study population. The people having positive and negative values are having very few common points. Out of 268 people who are having a score of negative value 101 people are having R.A and 11 are having history of broken bones i.e., 37.6% and 4.1% respectively. Where as in people who are having positive score (232) 177 are having R.A i.e., 76.9% and 108 are having history of broken bones. The final score is mainly depending on the age of the individual as the age increase final score also increases i.e. risk of osteoporosis also increases. The mean values of the final scores of the patients who are having ≥6 are calculated and are plotted in Fig. 5. according to their ages. n = 149

Mean Value of Total Score Mean value of total …

0 0 80

Fig. 5. Mean score in age groups Correlation between the person’s age and SCORE value: p values of final scores of different age groups in the study population are reported in Table. 3. Table. 3. The p-values of the study population Age of the patients Less than 65 years 65 – 69 years 70 – 79 Years Greater than 80 years

www.wjpps.com

Mean 0 15.24 18.05 20.9

p values 0 0.0429 >0.05 >0.05

Vol 3, Issue 5, 2014.

Comment No values Significant Very few data Very few data

1038

Vamsi et al.

World Journal of Pharmacy and Pharmaceutical Sciences

HIP FRACTURE In this part we collected 20 cases of the patients who are suffering with hip fracture. Patient details and their social habits where documented. Out of 20 patients 4 where males and remaining where females reported in Fig. 6. Representing Age distribution in patients with hip fracture.

Number

7 7 6 5 4 3 2 1 0

7

n = 20 4

2 Number 40-49 years

50-59 years

60-69 years

70-79 years

Age

Fig. 6. Age distribution in patients with hip fracture

Sex ratio Male 20%

Female 80%

Fig. 7. Sex ratio in study population The risk factors on osteoporosis like smoking habits, alcohol intake, caffeine and tea intake were also assessed and reported in Fig. 8, Fig. 9 and Fig. 10 respectively.

www.wjpps.com

Vol 3, Issue 5, 2014.

1039

Vamsi et al.

World Journal of Pharmacy and Pharmaceutical Sciences

Smoking

Number

15 10

13

5

7 0 Smokers

Non smokers Smoking habbit

Fig. 8. Smoking habit in study population

Number

Alcoholisim

20 15 10 5 0

17 3 Alcoholic

Non alcoholic

Alcoholic habit

Fig. 9. Alcohol intake in study population Usage of coffee,tea,cola 7% 33% 33%

only tea only coffee

27%

coffee&tea coffee,tea&cola

Fig. 10. Alcohol intake in study population Patient’s knowledge assessment Patient’s knowledge assessment is analyzed and reported in Fig. 11, which are categorized based on the responses given by them.

www.wjpps.com

Vol 3, Issue 5, 2014.

1040

Vamsi et al.

World Journal of Pharmacy and Pharmaceutical Sciences

25

n = 20

Number

20

1

2 3

15

3

4

6

8

10

Good

16

15

Excellent

13

9

5

Fair Poor

0 About About current About life style osteoporosis medications modifications Patients knowledge

About risk reduction

Fig. 11. Patient knowledge assessment

Number

The following data in Fig. 12. represent the adherence towards medication use in patients. 8 6 4 2 0

n = 20

Medication Adherence

4

3

8

5

Knowledge

Fig. 12. Medication adherence in study population. DISCUSSION The current study was carried out for a period of six months in the orthopaedic departments of three selected hospitals in Anantapur and 500 patients were included in the study. Risk of osteoporosis in women above age 45 was estimated for all the patients .This study reports that there is a high incidence of risk for osteoporosis. In the study it was found that most of the women (65.60%) attending orthopaedic OP’s are in between the age of 45 to 65 years. From the risk assessment SCORE questionnaire it was found that 149 patients (score ≥6) are at the risk of osteoporosis. Among them 85% were having a final score between 11 to 20. Patients were having complications like rheumatoid arthritis (56%) and broken bones (27%) which were the known indications for the occurrence of osteoporosis. 56.3% of women were at no risk zone and 46% of the women were having a risk for osteoporosis and needed tests for finding bone mineral density. It was found that the risk of osteoporosis was highly related

www.wjpps.com

Vol 3, Issue 5, 2014.

1041

Vamsi et al.

World Journal of Pharmacy and Pharmaceutical Sciences

to the age of the women. After menopause, the risk of osteoporosis increased with the increase in age. Statistically significant relation was found for the patients between age of 65 to 69 years.(Pvalue: 0.0429). It was found that females were having more risk for hip fractures. Out of 20 patients admitted in the hospital due to hip fractures (80%) were females. 35% of the patients were smokers and 15% of the patients were alcoholics which were the known risk factors for occurrence of osteoporosis. Food habits like drinking coffee (27%), tea (33%) were seen in patients who increase the risk for osteoporosis. Proper counseling of the patient regarding disease, medications and life style modifications improved the medication adherence in the hip fracture patients. Patients’ socio-economic status might be a factor for none of the women in our study were using oestrogen supplementation. High fluoride content in the drinking water in this district can be the reason of increased risk for osteoporosis and bone fracture. This study points out that lots of women above 45years in the Anantapur district are at a higher risk for developing osteoporosis and bone fracture. Unavailability of DXA scan machine in this district was a major problem in confirming the osteoporosis in our high risk patients. Alternative methods for finding out the bone mineral density are highly recommended in this population. Pharmacists could generate awareness about the nutrition and lifestyle modification that can decrease the incidence of osteoporosis in this vulnerable population. CONCLUSION From the study it was found that Females with increasing age are at more risk for developing osteoporosis. This study points out that lots of women above 45years in the Anantapur district are at a higher risk for developing osteoporosis and bone fracture. Unavailability of DXA scan machine in this district was a major problem in confirming the osteoporosis in our high risk patients. Alternative methods for finding out the bone mineral density are highly recommended in this population. Patients’ socio-economic status might be a factor for none of the women in our study were using oestrogen supplementation. High fluoride content in the drinking water in this district can be the reason of increased risk for osteoporosis and bone fracture.

www.wjpps.com

Vol 3, Issue 5, 2014.

1042

Vamsi et al.

World Journal of Pharmacy and Pharmaceutical Sciences

REFERENCES 1. J.T Dipiro, R.L Talbert, G.C. Yee, G.R.Matze Pharmacotherapy. A Pathophysiologic Approach 5th Edition. McGraw-Hill 2003. 2. CV Harinarayan, Alok Sachan et al. Vitamin D Status and Bone Mineral Density in Women of Reproductive and Postmenopausal Age Groups. JAPI. November2011. vol.59. 3. R Rizzoli, J-P Bonjour et al. Osteoporosis, genetics and hormones in Journal of Molecular Endocrinology. 2001. 26, 79–94.

www.wjpps.com

Vol 3, Issue 5, 2014.

1043