Cost-Effectiveness of Sequential Teriparatide/Alendronate Versus Alendronate-Alone Strategies in High-Risk Osteoporotic Women in the US: Analyzing the Impact of Generic/Biosimilar Teriparatide

Preoperative teriparatide intervention is cost-effective for osteoporotic patients undergoing lumbar fusion: a break-even cost analysis

BACKGROUND CONTEXT

Lumbar spinal fusion is a common procedure increasingly being performed in older patients many of whom have poor bone quality. Poor bone quality is associated with increased risk of bone related complications and need for revision surgery. Preoperative bone health optimization has been proposed to address this poor bone health using anti-osteoporosis medications. However, there remains ongoing controversy regarding the use of bisphosphonates and teriparatide for osteoporotic patients and few studies have explored the cost-effectiveness of teriparatide in lumbar spinal fusion.

PURPOSE

The aim of the study is to determine the cost-effectiveness, quantified in terms of absolute risk reduction (ARR) and number needed to treat (NNT), of teriparatide to prevent symptomatic pseudarthrosis following lumbar spinal fusion.

STUDY DESIGN/SETTING

Economic analysis, Level of Evidence 3.

PATIENT SAMPLE

The present break-even analysis considers simulated patients with and without osteoporosis undergoing primary posterior lumbar spinal fusion. The analysis is independent of the total number of annual surgeries and can be applied to any sized cohort of patients with osteoporosis undergoing primary posterior lumbar spinal fusion.

OUTCOME MEASURES

We calculated the final break-even cost rate of pseudoarthrosis, the absolute risk reduction, and the number need to treat to prevent one symptomatic pseudoarthrosis event while breaking even on cost utilization.

METHODS

The MEDLINE database was queried for prior literature regarding the cost of teriparatide and revision lumbar fusion surgery for symptomatic pseudarthrosis in the United States as well as the rate of symptomatic bony nonunion in osteoporotic patients undergoing spinal fusion. Two break-even cost analyses were performed utilizing the surgical cost alone and the total overall cost to calculate the ARR in pseudarthrosis required to deem teriparatide as cost-effective. The ARR was then used to calculate the number of patients that would require teriparatide, NNT, to prevent one pseudarthrosis event while breaking-even on overall cost expenditure.

RESULTS

When observing surgical cost alone, daily-use teriparatide was determined to be positively cost effective at initial rates of pseudarthrosis >53.4% in osteoporotic patients. Utilization of the total overall cost in our break-even model showed daily-use teriparatide to be cost effective when the initial nonunion rate exceeded 30.6%. Teriparatide was not cost-effective at lower initial rates of pseudarthrosis for osteoporotic patients. In both scenarios of investigating total overall cost and surgical cost alone, the ARR decreases as the cost of symptomatic pseudarthrosis treatment rises. At higher costs of revision surgery and higher initial pseudarthrosis rates, teriparatide becomes cost-effective at a more efficient rate.

CONCLUSIONS

Daily-use teriparatide is a cost-effective treatment for preventing symptomatic pseudarthrosis in osteoporotic patients undergoing lumbar spinal fusion, with a NNT of 5 in this population.

Cost-Effectiveness of Artificial Intelligence-Based Opportunistic Compression Fracture Screening of Existing Radiographs

PURPOSE

Osteoporotic vertebral compression fractures (OVCFs) are a highly prevalent source of morbidity and mortality, and preventive treatment has been demonstrated to be both effective and cost effective. To take advantage of the information available on existing chest and abdominal radiographs, the authors' study group has developed software to access these radiographs for OVCFs with high sensitivity and specificity using an established artificial intelligence deep learning algorithm. The aim of this analysis was to assess the potential cost-effectiveness of implementing this software.

METHODS

A deterministic expected-value cost-utility model was created, combining a tree model and a Markov model, to compare the strategies of opportunistic screening for OVCFs against usual care. Total costs and total quality-adjusted life-years were calculated for each strategy. Screening and treatment costs were considered from a limited societal perspective, at 2022 prices.

RESULTS

In the base case, assuming a cost of software implantation of $10 per patient screened, the screening strategy dominated the nonscreening strategy: it resulted in lower cost and increased quality-adjusted life-years. The lower cost was due primarily to the decreased costs associated with fracture treatment and decreased probability of requiring long-term care in patients who received preventive treatment. The screening strategy was dominant up to a cost of $46 per patient screened.

CONCLUSIONS

Artificial intelligence-based opportunistic screening for OVCFs on existing radiographs can be cost effective from a societal perspective.

Unchanged incidence of major adverse events amidst rising surgical interventions for osteoporotic vertebral fractures, 2015-2021

This study investigated treatment trends and major adverse events in patients hospitalized for osteoporotic vertebral fracture (OVF). The frequency of surgical interventions for OVF increased significantly, but this did not decrease major adverse events. The findings underscore the necessity for reevaluating OVF management strategies.

PURPOSE

Osteoporotic vertebral fracture (OVF) is a common condition in the aging population, often leading to increased morbidity and mortality. Here, we analyzed treatment trends and incidence of major adverse events in patients hospitalized for OVF.

METHODS

We conducted a cross-sectional descriptive study, using a large Japanese hospital administrative database. The cohort included hospitalized patients aged 65 years or older, admitted for OVF from January 2015 to December 2021. The primary outcomes were the trend in the proportion of the patients undergoing surgery for OVF and the incidence of major adverse events within 30 days of admission. As a secondary outcome, we evaluated the trend in hospitalization costs.

RESULTS

The study cohort consisted of 14,714 patients, with a mean age of 82.4 years. There was a significant increase in surgical interventions for OVF, from 3.7% of patients in 2015 to 9.8% in 2021 (p < 0.001). The incidence of major adverse events remained unchanged, with a risk ratio of 1.09 (95% confidence interval, 0.88 to 1.35) in 2021 compared to 2015. Average hospitalization costs increased significantly, from $7,570.6 (SD 6,047.0) in 2015 to $9,502.9 (SD 7,231.5) in 2021 (p < 0.001).

CONCLUSION

Despite a significant increase in the proportion of surgical intervention for OVF, no reduction in the risk of major adverse events was observed between 2015 and 2021. Surgeons and policy makers need to interpret these findings and work towards an optimized approach to the management of OVF in the aging population.

The cost-effectiveness of osteoporosis medications for preventing periprosthetic fractures following femoral neck fracture indicated hip arthroplasty: a break-even analysis

Osteoporosis treatment following arthroplasty for femoral neck fracture (FNF) is associated with lower rates of periprosthetic fracture (PPF). Our study evaluated the economic viability of treatment in patients following arthroplasty and demonstrates that treatment with oral bisphosphonates can be cost-effective in preventing PPF.

INTRODUCTION

Osteoporosis treatment following arthroplasty for femoral neck fracture (FNF) is associated with lower rates of periprosthetic fracture (PPF). Although cost-effective in reducing the rate of secondary fragility fracture, the economic viability of osteoporosis treatment in preventing PPF has not been evaluated. Therefore, the purpose of this study is to use a break-even analysis to determine whether and which current osteoporosis medications are cost-effective in preventing PPF following arthroplasty for FNFs.

METHODS

Three-year average cost of osteoporosis medication (oral bisphosphonates, estrogen hormonal therapy, intravenous (IV) bisphosphonates, denosumab, teriparatide, and abaloparatide), costs of PPF care, and PPF rates in patients who underwent hip arthroplasty for FNFs without osteoporosis treatment were used to perform a break-even analysis. The absolute risk reduction (ARR) related to osteoporosis treatment and sensitivity analyses were used to evaluate the cost-effectiveness of this intervention and break-even PPF rates.

RESULTS

Oral bisphosphonate therapy following arthroplasty for hip fractures would be economically justified if it prevents one out of 56 PPFs (ARR, 1.8%). Given the current cost and incidence of PPF, overall treatment can only be economically viable for PPF prophylaxis if the 3-year costs of these agents are less than $1500.

CONCLUSION

The utilization of lower cost osteoporosis medications such as oral bisphosphonates and estrogen hormonal therapy as PPF prophylaxis in this patient population would be economically viable if they reduce the PPF rate by 1.8% and 1.5%, respectively. For IV bisphosphonates and newer agents to be economically viable as PPF prophylaxis in the USA, their costs need to be significantly reduced.

Cost Effectiveness Analyses of Interventions for Osteoporosis in Men: A Systematic Literature Review

BACKGROUND

Osteoporosis is often considered to be a disease of women. Over the last few years, owing to the increasing clinical and economic burden, the awareness and imperative for identifying and managing osteoporosis in men have increased substantially. With the approval of agents to treat men with osteoporosis, more economic evaluations have been conducted to assess the potential economic benefits of these interventions. Despite this concern, there is no specific overview of cost-effectiveness analyses for the treatment of osteoporosis in men.

OBJECTIVES

This study aims (1) to systematically review economic evaluations of interventions for osteoporosis in men; (2) to critically appraise the quality of included studies and the source of model input data; and (3) to investigate the comparability of results for studies including both men and women.

METHODS

A literature search mainly using MEDLINE (via Ovid) and Embase databases was undertaken to identify original articles published between 1 January, 2000 and 30 June, 2022. Studies that assessed the cost effectiveness of interventions for osteoporosis in men were included. The Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases and the International Osteoporosis Foundation osteoporosis-specific guideline was used to assess the quality of design, conduct, and reporting of included studies.

RESULTS

Of 2973 articles identified, 25 studies fulfilled the inclusion criteria, classified into economic evaluations of active drugs (n = 8) or nutritional supplements (n = 4), intervention thresholds (n = 5), screening strategies (n = 6), and post-fracture care programs (n = 2). Most studies were conducted in European countries (n = 15), followed by North America (n = 9). Bisphosphonates (namely alendronate) and nutritional supplements were shown to be generally cost effective compared with no treatment in men over 60 years of age with osteoporosis or prior fractures. Two other studies suggested that denosumab was cost effective in men aged 75 years and older with osteoporosis compared with bisphosphates and teriparatide. Intervention thresholds at which bisphosphonates were found to be cost effective varied among studies with a 10-year probability of a major osteoporotic fracture that ranged from 8.9 to 34.2% for different age categories. A few studies suggested cost effectiveness of screening strategies and post-fracture care programs in men. Similar findings regarding the cost effectiveness of drugs and intervention thresholds in women and men were captured, with slightly greater incremental cost-effectiveness ratios in men. The quality of the studies included had an average score of 18.8 out of 25 (range 13-23.5). Hip fracture incidence and mortality risk were mainly derived from studies in men, while fracture cost, treatment efficacy, and disutility were commonly derived from studies in women or studies combining both sexes.

CONCLUSIONS

Anti-osteoporosis drugs and nutritional supplements are generally cost effective in men with osteoporosis. Screening strategies and post-fracture care programs also showed economic benefits for men. Cost-effectiveness and intervention thresholds were generally similar in studies conducted in both men and women, with slightly greater incremental cost-effectiveness ratios in men.

Pharmacologic Treatment of Primary Osteoporosis or Low Bone Mass to Prevent Fractures in Adults: A Living Clinical Guideline From the American College of Physicians

DESCRIPTION

This guideline updates the 2017 American College of Physicians (ACP) recommendations on pharmacologic treatment of primary osteoporosis or low bone mass to prevent fractures in adults.

METHODS

The ACP Clinical Guidelines Committee based these recommendations on an updated systematic review of evidence and graded them using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

AUDIENCE AND PATIENT POPULATION

The audience for this guideline includes all clinicians. The patient population includes adults with primary osteoporosis or low bone mass.

RECOMMENDATION 1A

ACP recommends that clinicians use bisphosphonates for initial pharmacologic treatment to reduce the risk of fractures in postmenopausal females diagnosed with primary osteoporosis (strong recommendation; high-certainty evidence).

RECOMMENDATION 1B

ACP suggests that clinicians use bisphosphonates for initial pharmacologic treatment to reduce the risk of fractures in males diagnosed with primary osteoporosis (conditional recommendation; low-certainty evidence).

RECOMMENDATION 2A

ACP suggests that clinicians use the RANK ligand inhibitor (denosumab) as a second-line pharmacologic treatment to reduce the risk of fractures in postmenopausal females diagnosed with primary osteoporosis who have contraindications to or experience adverse effects of bisphosphonates (conditional recommendation; moderate-certainty evidence).

RECOMMENDATION 2B

ACP suggests that clinicians use the RANK ligand inhibitor (denosumab) as a second-line pharmacologic treatment to reduce the risk of fractures in males diagnosed with primary osteoporosis who have contraindications to or experience adverse effects of bisphosphonates (conditional recommendation; low-certainty evidence).

RECOMMENDATION 3

ACP suggests that clinicians use the sclerostin inhibitor (romosozumab, moderate-certainty evidence) or recombinant PTH (teriparatide, low-certainty evidence), followed by a bisphosphonate, to reduce the risk of fractures only in females with primary osteoporosis with very high risk of fracture (conditional recommendation).

RECOMMENDATION 4

ACP suggests that clinicians take an individualized approach regarding whether to start pharmacologic treatment with a bisphosphonate in females over the age of 65 with low bone mass (osteopenia) to reduce the risk of fractures (conditional recommendation; low-certainty evidence).

Cost-effectiveness analysis of five drugs for treating postmenopausal women in the United States with osteoporosis and a very high fracture risk

PURPOSE

Five strategies were recommended by the American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) guidelines for the treatment of postmenopausal osteoporosis (PMO) patients with a very high fracture risk. We aimed to assess their cost-effectiveness in the United States (US).

METHODS

A microsimulation Markov model was created to compare the cost-effectiveness of five treatment strategies, including zoledronate, denosumab, abaloparatide, teriparatide, and romosozumab in PMO patients with a recent fracture from the healthcare perspective of the US. The data used in the model were obtained from published studies or online resources. Base-case analysis, one-way deterministic sensitivity analysis (DSA) and probability sensitivity analysis (PSA) were conducted for 65-, 70-, 75-, and 80-year-old patients.

RESULTS

In base case, at 65 years, zoledronate was the cheapest strategy. The incremental cost-effectiveness ratios (ICER, which represent incremental costs per QALY gained) of denosumab, teriparatide, abaloparatide, and romosozumab against zoledronate were $13,020/QALY (quality-adjusted years), $477,331 /QALY, $176,287/QALY, and $98,953/QALY, respectively. Under a willing-to-pay (WTP, which means the highest price a consumer will pay for one unit of a good of service) threshold of $150,000/QALY, denosumab and romosozumab were cost-effective against zoledronate. The PSA results showed that denosumab was the most cost-effective option with WTP thresholds of $50,000/QALY, $100,000/QALY and $150,000/QALY. The results were similar in other age groups. The DSA results indicated that the most common parameters that have important influence on the outcome were drug persistence, incidence of adverse events, the efficacy of drugs on hip fractures and the cost of the drug.

CONCLUSION AND RELEVANCE

Among PMO patients with a very high fracture risk in the US, zoledronate is the cheapest strategy and denosumab is the most cost-effective choice among these five strategies.

A systematic review of cost‑effectiveness analyses of sequential treatment for osteoporosis

Sequential treatment of osteoporosis has been increasingly mentioned in recent years. However, the corresponding systematic review has not been reported. This study aims to systematically review and assess all full-text pharmacoeconomic studies of sequential treatment for osteoporosis. A comprehensive literature search was performed using PubMed, EMBASE (Ovid), CNKI, and Wanfang Database to identify original articles, published before June 17, 2022. The quality of included articles was evaluated by the updated Consolidated Health Economic Evaluation Reporting Standards (CHEERS 2022) and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases International Osteoporosis Foundation (ESCEO-IOF). In general, ten articles were included in this review. For the comparison between sequential treatment and bisphosphonate monotherapy, more than 75% of studies demonstrated the sequential treatment was cost-effective or dominant, with the exception of sequential treatment involving teriparatide. When the comparisons occurred between the two sequential treatment groups, the sequential treatments associated with either abaloparatide or romosozumab were cost-effective or dominant compared to the sequential treatment involving teriparatide. Several major key drivers of cost-effectiveness included drug cost, medication persistence and adherence, drug effect on fracture risk, offset effect, time horizon, and baseline fracture risk. The most of studies were identified as high quality in CHEERS (2022) and ESCEO-IOF. The cost-effectiveness of sequential treatment for osteoporosis is influenced by multiple factors. Generally, the sequential treatments involving abaloparatide, romosozumab, denosumab, and bisphosphonates may be considered as the preferred option for osteoporosis with high fracture risk, while the sequential treatment with teriparatide was not a cost-effectiveness strategy. The ESCEO-IOF and CHEER (2022) increase the transparency, comparability, extrapolation, and quality of research, engage patients and the general public in research on health services and policies, and help improve the quality of health technology assessment.

Medical optimization of osteoporosis for adult spinal deformity surgery: a state-of-the-art evidence-based review of current pharmacotherapy

PURPOSE

Osteoporosis is a common, but challenging phenomenon to overcome in adult spinal deformity (ASD) surgery. Several pharmacological agents are at the surgeon's disposal to optimize the osteoporotic patient prior to undergoing extensive reconstruction. Familiarity with these medications will allow the surgeon to make informed decisions on selecting the most appropriate adjuncts for each individual patient.

METHODS

A comprehensive literature review was conducted in PubMed from September 2021 to April 2022. Studies were selected that contained combinations of various terms including osteoporosis, specific medications, spine surgery, fusion, cage subsidence, screw loosening, pull-out, junctional kyphosis/failure.

RESULTS

Bisphosphonates, denosumab, selective estrogen receptor modulators, teriparatide, abaloparatide and romosozumab are all pharmacological agents currently available for adjunctive use. While these medications have been shown to have beneficial effects on improving bone mineral density in the osteoporotic patient, varying evidence is available on their specific effects in the context of extensive spine surgery. There is still a lack of human studies with use of the newer agents.

CONCLUSION

Bisphosphonates are first-line agents due to their low cost and robust evidence behind their utility. However, in the absence of contraindications, optimizing bone quality with anabolic medications should be strongly considered in preparation for spinal deformity surgeries due to their beneficial and favorable effects on fusion and hardware compared to the anti-resorptive medications.

Cost-utility Analysis of Neoadjuvant Teriparatide Therapy in Osteopenic Patients Undergoing Adult Spinal Deformity Surgery

STUDY DESIGN

A cost-utility analysis study.

OBJECTIVE

This study aims to evaluate the cost-utility of neoadjuvant teriparatide therapy in osteopenic patients undergoing adult spinal deformity (ASD) surgery.

SUMMARY OF BACKGROUND DATA

There is increasing evidence supporting preoperative use of anabolic agents such as teriparatide for preoperative optimization of ASD patients with poor bone density. However, such treatments are associated with added costs. To our knowledge, the cost-utility of teriparatide in osteopenic patients undergoing ASD surgery has not been established.

MATERIALS AND METHODS

A decision-analysis model was developed for a hypothetical 68-year-old female patient with osteopenia ( T score <-1.0) undergoing a T11 to pelvis instrumented spinal fusion for ASD. A comprehensive literature review was conducted to create estimates for event probabilities, costs, and quality adjusted life years at each node. Key model assumptions were that administration of a 4-month preoperative teriparatide course reduced 2-year postoperative reoperation rates [for pseudarthrosis from 5% to 2.5% and for proximal junctional failure (PJF) from 15% to 5%]. Monte Carlo simulations were used to calculate the mean incremental cost utility ratio and incremental net monetary benefits. One-way sensitivity analysis was used to estimate the contribution of individual parameters to uncertainty in the model.

RESULTS

Teriparatide was the favored strategy in 82% of the iterations. The mean incremental cost utility ratio for the teriparatide strategy was negative (higher net benefit, lower net cost), and lower than the willingness-to-pay threshold of $50,000 per quality adjusted life year. Teriparatide use was associated with a mean incremental net monetary benefit of $3,948. One-way sensitivity analysis demonstrated that the factors with the greatest impact on the model were the incidence of PJF in the no teriparatide group, the duration and monthly cost of treatment, and the cost of reoperation due to PJF.

CONCLUSIONS

Neoadjuvant teriparatide is a cost-effective strategy to reduce postoperative complications in patients with osteopenia undergoing ASD surgery.

Management of patients at very high risk of osteoporotic fractures through sequential treatments

Osteoporosis care has evolved markedly over the last 50 years, such that there are now an established clinical definition, validated methods of fracture risk assessment and a range of effective pharmacological agents. Currently, bone-forming (anabolic) agents, in many countries, are used in those patients who have continued to lose bone mineral density (BMD), patients with multiple subsequent fractures or those who have fractured despite treatment with antiresorptive agents. However, head-to-head data suggest that anabolic agents have greater rapidity and efficacy for fracture risk reduction than do antiresorptive therapies. The European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) convened an expert working group to discuss the tools available to identify patients at high risk of fracture, review the evidence for the use of anabolic agents as the initial intervention in patients at highest risk of fracture and consider the sequence of therapy following their use. This position paper sets out the findings of the group and the consequent recommendations. The key conclusion is that the current evidence base supports an "anabolic first" approach in patients found to be at very high risk of fracture, followed by maintenance therapy using an antiresorptive agent, and with the subsequent need for antiosteoporosis therapy addressed over a lifetime horizon.

Cost-Effectiveness of Sequential Denosumab/Zoledronic Acid Compared With Zoledronic Acid Monotherapy for Postmenopausal Osteoporotic Women in China

Objective: The primary purpose of this study was to estimate the cost-effectiveness of sequential denosumab/zoledronic acid versus zoledronic acid monotherapy for postmenopausal osteoporotic women in China.

Methods: We updated and utilized a previously validated Markov microsimulation model to obtain the cost-effectiveness of two strategies for treating postmenopausal osteoporotic women. We compared the incremental cost-effectiveness ratios (ICERs) (US dollars [$] per quality-adjusted life year [QALY]) of sequential denosumab/zoledronic acid (i.e., biannual subcutaneous denosumab for 3 years followed by annual intravenous zoledronic acid for 3 years) with zoledronic acid monotherapy for 3 years in Chinese women with postmenopausal osteoporosis at ages 65, 70, 75, and 80 from the health care payer perspective. Our study’s willingness-to-pay (WTP) threshold was set to three times the value of China’s per capita GDP in 2020 ($31,512).

Results: The ICERs of sequential denosumab/zoledronic acid versus zoledronic acid monotherapy were $59,389/QALY, $23,821/QALY, $22,710/QALY, and $14,027/QALY at age 65, 70, 75, and 80 years, respectively. One-way sensitivity analyses showed that the most impactful parameter was the persistence rate of the medications. If the persistence rate of denosumab or zoledronic acid was increased by 10%, sequential denosumab/zoledronic acid would be cost-effective at age 65. In probabilistic sensitivity analyses, the probabilities of sequential denosumab/zoledronic being cost-effective compared to zoledronic acid monotherapy were approximately 29.3%, 68.7%, 86.1%, and 99.4% for ages 65, 70, 75, and 80 years, respectively, at the WTP threshold of $31,512/QALY.

Conclusion: Among Chinese postmenopausal osteoporosis women over 70 years old, sequential denosumab/zoledronic acid was cost-effective compared with zoledronic acid monotherapy at the pre-determined WTP threshold.

Optimal timing for intermittent administration of parathyroid hormone (1-34) for distraction osteogenesis in rabbits

Background

To date, the usefulness of parathyroid hormone [PTH (1–34)] in distraction osteogenesis has been reported in several studies. We aimed to determine the optimal timing of PTH (1–34) administration in a rabbit distraction osteogenesis model.

Methods

The lower hind leg of a Japanese white rabbit was externally fixed, and tibial osteotomy was performed. One week after the osteotomy, bone lengthening was carried out at 0.375 mm/12 h for 2 weeks. After 5 weeks, the lower leg bone was collected. Bone mineral density (BMD), peripheral quantitative computed tomography (pQCT), micro-computed tomography (micro-CT), and mechanical tests were performed on the distracted callus. The rabbits were divided into three groups according to the timing of PTH (1–34) administration: 4 weeks during the distraction and consolidation phases (group D + C), 2 weeks of the distraction phase (group D), and the first 2 weeks of the consolidation phase (group C). A control group (group N) was administered saline for 4 weeks during the distraction and consolidation phases. Furthermore, to obtain histological findings, lower leg bones were collected from each rabbit at 2, 3, and 4 weeks after osteotomy, and tissue sections of the distracted callus were examined histologically.

Results

The BMD was highest in group C and was significantly higher than group D. In pQCT, the total cross-sectional area was significantly higher in groups D + C, D, and C than group N, and the cortical bone area was highest in group C and was significantly higher than group D. In micro-CT, group C had the highest bone mass and number of trabeculae. Regarding the mechanical test, group C had the highest callus failure strength, and this value was significantly higher compared to group N. There was no significant difference between groups D and N. The histological findings revealed that the distracted callus mainly consisted of endochondral ossification in the distraction phase. In the consolidation phase, the chondrocytes were almost absent, and intramembranous ossification was the main type of ossification.

Conclusion

We found that the optimal timing of PTH (1–34) administration is during the consolidation phase, which is mainly characterized by intramembranous ossification.

Cost-Effectiveness of Sequential Teriparatide/Zoledronic Acid Compared With Zoledronic Acid Monotherapy for Postmenopausal Osteoporotic Women in China

Objective

We aimed to assess the cost-effectiveness of sequential teriparatide/zoledronic acid relative to zoledronic acid monotherapy for postmenopausal osteoporotic women in China.

Methods

A previously validated Markov microsimulation model was updated to examine the cost-effectiveness of daily subcutaneous teriparatide for 2 years followed by annual intravenous zoledronic acid for 3 years (sequential teriparatide/zoledronic acid), compared with zoledronic acid monotherapy for 3 years in Chinese women with postmenopausal osteoporosis at ages 65, 70, 75, and 80 from the health care payer perspective.

Results

The incremental cost-effectiveness ratios (ICERs) (US dollars [$] per quality-adjusted life-year [QALY]) of sequential teriparatide/zoledronic acid vs. zoledronic acid monotherapy was $173,223/QALY at age 65 years, which was much higher than the pre-determined willingness-to-pay (WTP) threshold of $ 31,512/QALY, and the results were similar at other ages. In one-way sensitivity analyses, the two most impactful parameters were the cost of teriparatide and the residual effects of the medications included in this study. Sequential teriparatide/zoledronic acid became cost-effective at age 80 with the cost of teriparatide reduced by 50%. Without the residual effect, the ICER increased to $257,982/QALY. Probabilistic sensitivity analyses shown that the probabilities of zoledronic acid monotherapy being cost-effective were 100% at a WTP of $31,512/QALY.

Conclusions

Among Chinese women with postmenopausal osteoporosis, sequential teriparatide/zoledronic acid was not cost-effective unless the cost of teriparatide was reduced by 50% only for the participants over 80 years.

A novel economic framework to assess the cost-effectiveness of bone-forming agents in the prevention of fractures in patients with osteoporosis

A novel cost-effectiveness model framework was developed to incorporate the elevated fracture risk associated with a recent fracture and to allow sequential osteoporosis therapies to be evaluated. Treating patients with severe osteoporosis after a recent fracture with a bone-forming agent followed by antiresorptive therapy can be cost-effective compared with antiresorptive therapy alone. Incorporating these novel technical attributes in economic evaluations can support appropriate policy and reimbursement decision-making.

PURPOSE

To develop a cost-effectiveness model accommodating increased fracture risk after a recent fracture and treatment sequencing.

METHODS

A micro-simulation cost-utility model was developed to accommodate both treatment sequencing and increased risk with recent fracture. The risk of fracture was estimated and simulated using the FRAX® algorithms combined with Swedish registry data on imminent fracture relative risk. In the base-case cost-effectiveness analysis, a sequential treatment starting with a bone-forming agent for 12 months followed by an antiresorptive agent for 48 months initiated immediately after a major osteoporotic fracture (MOF) in a 70-year-old woman with a T-score of 2.5 or less was compared to an antiresorptive treatment alone for 60 months. The model was populated with data relevant for a UK population reflecting a personal social service perspective.

RESULTS

The cost per additional quality-adjusted life year (QALY) gained in the base-case setting was estimated at £34,584. Sensitivity analyses revealed the sequential treatment to be cost-saving compared with administering a bone-forming treatment alone. Without simulating an elevated fracture risk immediately after a recent fracture, the cost per QALY changed from £34,584 to £62,184.

CONCLUSION

Incorporating imminent fracture risk in economic evaluations has a significant impact on the cost-effectiveness when evaluating fracture prevention treatments in patients with osteoporosis who sustained a recent fracture. Bone-forming treatment followed by antiresorptive therapy can be cost-effective compared to antiresorptive therapy alone depending on treatment acquisition costs.

Anabolic treatments for osteoporosis in postmenopausal women

Antiresorptive agents are generally recommended as first-line treatment for osteoporosis in postmenopausal women. These drugs suppress bone resorption but do not rebuild bone, limiting their efficacy. Antiresorptive use is further hampered by concerns over rare side effects, including atypical femoral fractures and osteonecrosis of the jaw. Anabolic treatments overcome limitations of antiresorptive treatment by stimulating new bone formation, reducing the risk of fracture with greater efficacy. This review summarises the latest trial data for the three anabolic agents currently available for the treatment of osteoporosis in postmenopausal women: teriparatide, abaloparatide, and romosozumab. Data from head-to-head studies comparing anabolic and antiresorptive treatments are reviewed. At present, anabolic treatments are generally reserved for use in patients with severe osteoporosis at very high fracture risk; the factors limiting their more widespread use are discussed together with how this may change in the future.

Review of Current Real-World Experience with Teriparatide as Treatment of Osteoporosis in Different Patient Groups

Teriparatide has proven effective in reducing both vertebral and non-vertebral fractures in clinical trials of post-menopausal and glucocorticoid-induced osteoporosis. Widespread adoption of Teriparatide over the last two decades means that there is now substantial experience of its use in routine clinical practice, which is summarized in this paper. Extensive real-world experience of Teriparatide in post-menopausal osteoporosis confirms the fracture and bone density benefits seen in clinical trials, with similar outcomes identified also in male and glucocorticoid-induced osteoporosis. Conversely, very limited experience has been reported in pre-menopausal osteoporosis or in the use of Teriparatide in combination with other therapies. Surveillance studies have identified no safety signals relating to the possible association of Teriparatide with osteosarcoma. We also review the evidence for predicting response to Teriparatide in order to inform the debate on where best to use Teriparatide in an increasingly crowded therapeutic landscape.

Role of bone-forming agents in the management of osteoporosis

Recent evidence confirms the superiority of osteoanabolic therapy compared to anti-remodeling drugs for rapid improvement in bone density and fracture risk reduction, providing strong justification for the use of these anabolic agents as the initial therapy in high-risk patients, to be followed by anti-remodeling therapy. This review will highlight the results of recent studies and define the current status of osteoanabolic therapy for osteoporosis.

An Updated Systematic Review of Cost-Effectiveness Analyses of Drugs for Osteoporosis

BACKGROUND

Considering the heavy economic burden of osteoporotic fractures, the limits of healthcare resources, and the recent availability of new anti-osteoporosis drugs, there is continuing interest in economic evaluation studies of osteoporosis management strategies.

OBJECTIVES

This study aims to (1) systematically review recent economic evaluations of drugs for osteoporosis and (2) to apply an osteoporosis-specific guideline to critically appraise them.

METHODS

A literature search was undertaken using PubMed, EMBASE, National Health Service Economic Evaluation database, and the Cost-Effectiveness Analysis Registry to identify original articles containing economic evaluations of anti-osteoporosis drugs, published between 1 July, 2013 and 31 December, 2019. A recent European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases-International Osteoporosis Foundation (ESCEO-IOF) guideline for the conduct and reporting of economic evaluations in osteoporosis was used to assess the quality of included articles.

RESULTS

The database search retrieved 3860 records, of which 27 studies fulfilled the inclusion criteria. These studies were conducted in 15 countries; 12 active drugs were assessed, including various traditional pharmacological treatments such as bisphosphonates, raloxifene, strontium ranelate, denosumab, and teriparatide, and new agents such as abaloparatide, romosozumab, and gastro-resistant risedronate. Eight out of 12 studies that compared traditional oral bisphosphonates to other active interventions (denosumab, zoledronic acid, gastro-resistant risedronate, and teriparatide) suggested that the other active agents were generally cost-effective or dominant. Additionally, the cost-effectiveness of sequential therapy has recently been assessed and indications are that it can lead to extra health benefits (larger gains in quality-adjusted life-year). The key drivers of cost effectiveness included baseline fracture risk, drug effect on the risk of fractures, drug cost, and medication adherence/persistence. The current average score for quality assessment was 17 out of 25 (range 2-15); room for improvement was observed for most studies, which could potentially be explained by the fact that most studies were published prior to the osteoporosis-specific guideline. Greater adherence to guideline recommendations was expected for future studies. The quality of reporting was also suboptimal, especially with regard to treatment side effects, treatment effect after discontinuation, and medication adherence.

CONCLUSIONS

This updated review provides an overview of recently published cost-effectiveness analyses. In comparison with a previous review, recent economic evaluations of anti-osteoporosis drugs were conducted in more countries and included more active drugs and sequential therapy as interventions/comparators. The updated economic evidence could help decision makers prioritize health interventions and the unmet/unreported quality issues indicated by the osteoporosis-specific guideline could be useful in improving the transparency, quality, and comparability of future economic evaluations in osteoporosis.

Cost-effectiveness of sequential daily teriparatide/weekly alendronate compared with alendronate monotherapy for older osteoporotic women with prior vertebral fracture in Japan

Using a Markov microsimulation model among hypothetical cohorts of community-dwelling older osteoporotic Japanese women with prior vertebral fracture over a lifetime horizon, we found that daily subcutaneous teriparatide for 2 years followed by weekly oral alendronate for 8 years was not cost-effective compared with alendronate monotherapy for 10 years.

PURPOSE

Teriparatide has proven efficacy in reducing osteoporotic fractures, but with substantial cost. We examined the cost-effectiveness of sequential teriparatide/alendronate (i.e., daily subcutaneous teriparatide for 2 years followed by weekly oral alendronate for 8 years) compared with alendronate monotherapy for 10 years among community-dwelling older osteoporotic women with prior clinical or morphometric vertebral fracture in Japan.

METHODS

Using a previously validated and updated Markov microsimulation model, we obtained incremental cost-effectiveness ratios (Japanese yen [¥] (or US dollars [$]) per quality-adjusted life year [QALY]) from the perspective of a single payer responsible for both public healthcare and long-term care. We assumed a lifetime horizon with a willingness-to-pay of ¥5million (or $47,500) per QALY in the base case. We modeled the cost of biosimilar teriparatide, which has been available since November 2019 in Japan, assuming the efficacy was the same as that of the brand version.

RESULTS

In the base case, sequential teriparatide/alendronate was not cost-effective compared with alendronate monotherapy. In deterministic sensitivity analyses, sequential teriparatide/alendronate would become cost-effective with 85%, 50%, and 15% price discounts to teriparatide at ages 70, 75, and 80, respectively, compared to the current biosimilar cost. Otherwise, results were especially sensitive to changes that affected efficacy of teriparatide or alendronate. In probabilistic sensitivity analyses, the probabilities of sequential teriparatide/alendronate being cost-effective were 0%, 1%, and 37% at ages 70, 75, and 80, respectively.

CONCLUSIONS

Among high-risk osteoporotic women in Japan, sequential teriparatide/alendronate was not cost-effective compared with alendronate monotherapy, even with the availability of biosimilar teriparatide.

Cost-effectiveness of zoledronic acid compared with sequential denosumab/alendronate for older osteoporotic women in Japan

Among hypothetical cohorts of older osteoporotic women without prior fragility fracture in Japan, we evaluated the cost-effectiveness of two treatment strategies using a simulation model. Annual intravenous zoledronic acid for 3 years was cost-saving compared with biannual subcutaneous denosumab for 3 years followed by weekly oral alendronate for 3 years.

PURPOSE

Osteoporosis constitutes a major medical and health economic burden to society worldwide. Injectable treatments for osteoporosis require less frequent administration than oral treatments and therefore have higher persistence and adherence with treatment, which could explain better efficacy for fracture prevention. Although annual intravenous zoledronic acid and biannual subcutaneous denosumab are available, it remains unclear which treatment strategy represents a better value from a health economic perspective. Accordingly, we examined the cost-effectiveness of zoledronic acid for 3 years compared with sequential denosumab/alendronate (i.e., denosumab for 3 years followed by oral weekly alendronate for 3 years, making the total treatment duration 6 years) among hypothetical cohorts of community-dwelling osteoporotic women without prior fragility fracture in Japan at ages 65, 70, 75, or 80 years.

METHODS

Using a previously validated and updated Markov microsimulation model, we obtained incremental cost-effectiveness ratios (Japanese yen [¥] (or US dollars [$]) per quality-adjusted life-year [QALY]) from the public healthcare and long-term care payer's perspective over a lifetime horizon with a willingness-to-pay of ¥5 million (or $47,500) per QALY.

RESULTS

In the base case, zoledronic acid was cost-saving (i.e., more effective and less expensive) compared with sequential denosumab/alendronate. In deterministic sensitivity analyses, results were sensitive to changes in the efficacy of zoledronic acid or the cumulative persistence rate with zoledronic acid or denosumab. In probabilistic sensitivity analyses, the probabilities of zoledronic acid being cost-effective were 98-100%.

CONCLUSIONS

Among older osteoporotic women without prior fragility fracture in Japan, zoledronic acid was cost-saving compared with sequential denosumab/alendronate.

Cost-Effectiveness of Zoledronic Acid Versus Oral Alendronate for Postmenopausal Osteoporotic Women in China

Objective

This study aims to estimate the cost-effectiveness of yearly intravenous zoledronic acid treatment versus weekly oral alendronate for postmenopausal osteoporotic women in China.

Methods

We used a Markov microsimulation model to compare the cost-effectiveness of zoledronic acid with alendronate in Chinese postmenopausal osteoporotic women with no fracture history at various ages of therapy initiation from health care payer perspective.

Results

The incremental cost-effectiveness ratios (ICERs) for the zoledronic acid versus alendronate were $23,581/QALY at age 65 years, $17,367/QALY at age 70 years, $14,714/QALY at age 75 years, and $12,169/QALY at age 80 years, respectively. In deterministic sensitivity analyses, the study demonstrated that the two most impactful parameters were the annual cost of zoledronic acid and the relative risk of hip fracture with zoledronic acid. In probabilistic sensitivity analyses, the probabilities of zoledronic acid being cost-effective compared with alendronate were 70–100% at a willingness-to-pay of $29,340 per QALY.

Conclusions

Among postmenopausal osteoporotic women in China, zoledronic acid therapy is cost-effective at all ages examined from health care payer perspective, compared with weekly oral alendronate. In addition, alendronate treatment is shown to be dominant for patients at ages 65 and 70 with full persistence. This study will help clinicians and policymakers make better decisions about the relative economic value of osteoporosis treatments in China.