Frequency of discontinuation of injectable osteoporosis therapies in US patients over 2 years

Bone loss and new vertebral fractures during treatment with romosozumab: a case-report

PURPOSE

This study aimed to illustrate the possibility of an unfavorable response to treatment with the anabolic agent romosozumab for patients with severe osteoporosis and to discuss explanations for treatment failure.

METHODS

Dual-energy x-ray absorptiometry (DXA) including vertebral fracture assessment (VFA) and X-rays of the thoracolumbar spine was used to assess bone mineral density (BMD) and the presence of vertebral fractures before and after treatment with romosozumab.

RESULTS

Our patient developed a decrease in the BMD of the hip, two incident new vertebral fractures, and worsening of one prevalent vertebral fracture during 1 year treatment with romosozumab. We have not detected non-adherence, there was no pretreatment with anti-resorptives, and we observed no signs of secondary osteoporosis and/or comorbidities.

CONCLUSION

As the number of patients treated with romosozumab is rising, it becomes more likely that more patients will be found with new fractures and/or an unfavorable BMD response. Probably, the unfavorable response is a (bad) chance finding, but we think it is crucial for clinicians and patients to exclude nonadherence, new comorbidities and pretreatment with anti-resorptives as explanation in these patients.

The interruption of romosozumab treatment during COVID lockdown among US post-menopausal women enrolled in Medicare

PURPOSE

To evaluate the impact of the COVID lock-down on treatment interruptions of romosozumab, a first in class biologic therapy, administered by healthcare providers once monthly.

METHODS

We used Medicare data from 1/1/2017 to 9/30/2021 to identify women age ≥65 initiating romosozumab between 4/1/2019 and 6/30/2021. Patient demographics, provider specialty, and baseline comorbidities were identified. Romosozumab dispensations were grouped into five 6-month periods based on the dispensing date from FDA licensure to the end of the data (Period 1 to 5). "Treatment interruption" was defined as any interval gap between 2 dispensations >60 days. The numbers of treatment interruption event were aggregated per period per patient. Mixed effect Poisson regression with patient-level random effects was performed, including an interaction term between Period and number of prior doses.

RESULTS

There were 12,216 romosozumab new users identified. A total of 2724 treatment interruption events were identified among 2229 romosozumab users. After adjustment, comparing with the period immediately before the lockdown (Period 2: 2019-10-1-2020-3-30), the IRRs (95 % CI) for treatment interruption were 0.49 (0.29, 0.81), 1.65 (1.48, 1.85), 1.79 (1.60, 2.01), and 1.67 (1.49, 1.87) for periods 1, 3, 4, and 5, respectively, per 1 prior dose change (p < 0.01 for all IRRs), where Periods 3, 4, and 5 were post-lockdown.

CONCLUSION

Compared to the pre-COVID period, the lockdown negatively impacted the continuity of romosozumab treatment among Medicare beneficiaries. Prioritizing in-time assistance for patients receiving a provider-administered parenteral therapy is critical when patients' in-person access to their provider is compromised.

Four-year treatment continuation rates of osteoporosis drugs with different dosing intervals throughout Japan

INTRODUCTION

There are approximately 13 million patients with osteoporosis in Japan; however, only 20% of them receive treatment. This study compared the 4-year continuation rates of osteoporosis drugs at different dosing intervals across throughout Japan.

MATERIALS AND METHODS

Receipt data were analyzed to determine the continuation of osteoporosis medication in patients who began treatment at 210 hospitals throughout Japan between October 2016 and September 2017. Continuation rates were compared using Kaplan-Meier curves and log-rank tests.

RESULTS

The 4-year continuation rates of daily, weekly, monthly, semi-annual, and yearly medications nationwide were 8.6%, 16.5%, 13.5%, 31.0%, and 26.0%, respectively. The 4-year continuation rates for semi-annual and yearly drugs were significantly higher than daily, weekly, monthly drugs.

CONCLUSION

Throughout Japan, the 4-year treatment continuation rates of daily, weekly, monthly, semi-annual, and yearly osteoporosis drugs all decreased over time. However, the continuation rates of semi-annual and yearly drugs in the fourth year were significantly higher than those for the other dosing regimens. Therefore, injectable drugs with dosing intervals ≥6 months may improve continuation rates of osteoporosis drugs. Geriatr Gerontol Int 2023; 23: 665-670.

Real-world evidence: new opportunities for osteoporosis research. Recommendations from a Working Group from the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO)

This narrative review summarises the recommendations of a Working Group of the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) for the conduct and reporting of real-world evidence studies with a focus on osteoporosis research.

PURPOSE

Vast amounts of data are routinely generated at every healthcare contact and activity, and there is increasing recognition that these real-world data can be analysed to generate scientific evidence. Real-world evidence (RWE) is increasingly used to delineate the natural history of disease, assess real-life drug effectiveness, understand adverse events and in health economic analysis. The aim of this work was to understand the benefits and limitations of this type of data and outline approaches to ensure that transparent and high-quality evidence is generated.

METHODS

A ESCEO Working Group was convened in December 2022 to discuss the applicability of RWE to osteoporosis research and approaches to best practice.

RESULTS

This narrative review summarises the agreed recommendations for the conduct and reporting of RWE studies with a focus on osteoporosis research.

CONCLUSIONS

It is imperative that research using real-world data is conducted to the highest standards with close attention to limitations and biases of these data, and with transparency at all stages of study design, data acquisition and curation, analysis and reporting to increase the trustworthiness of RWE study findings.

Persistence with Denosumab in Male Osteoporosis Patients: A Real-World, Non-Interventional Multicenter Study

BACKGRUOUND

Persistence with denosumab in male patients has not been adequately investigated, although poor denosumab persistence is associated with a significant risk of rebound vertebral fractures.

METHODS

We retrospectively evaluated 294 Korean male osteoporosis patients treated with denosumab at three medical centers and examined their persistence with four doses of denosumab injection over 24 months of treatment. Persistence was defined as the extent to which a patient adhered to denosumab treatment in terms of the prescribed interval and dose, with a permissible gap of 8 weeks. For patients who missed their scheduled treatment appointment(s) during the follow-up period (i.e., no-shows), Cox proportional regression analysis was conducted to explore the factors associated with poor adherence. Several factors were considered, such as age, prior anti-osteoporotic drug use, the treatment provider's medical specialty, the proximity to the medical center, and financial burdens of treatment.

RESULTS

Out of 294 male patients, 77 (26.2%) completed all four sequential rounds of the denosumab treatment. Out of 217 patients who did not complete the denosumab treatment, 138 (63.6%) missed the scheduled treatment(s). Missing treatment was significantly associated with age (odds ratio [OR], 1.03), prior bisphosphonate use (OR, 0.76), and prescription by non-endocrinologists (OR, 2.24). Denosumab was stopped in 44 (20.3%) patients due to medical errors, in 24 (11.1%) patients due to a T-score improvement over -2.5, and in five (2.3%) patients due to expected dental procedures.

CONCLUSION

Our study showed that only one-fourth of Korean male osteoporosis patients were fully adherent to 24 months of denosumab treatment.

A Narrative Review on Non-Invasive Drug Delivery of Teriparatide: A Ray of Hope

In the field of pharmaceutical biotechnology and formulation development, various protein and peptide-based drugs have been used for therapeutic and clinical implications. These are mainly given via parenteral routes like intravenous, subcutaneous or intramuscular delivery. Teriparatide, also known as PTH 1-34, is a U.S. Food & Drug Administartion-approved anabolic drug to treat osteoporosis is currently available in market only as subcutaneous injection. The quest for elimination of needle in case of given peptidal delivery to replace it with alternative routes like nasal, buccal, transdermal and pulmonary pathways has driven meticulous drug research. The pharmaceutical scientists are working on innovation and approaches involving new materials and methods to develop the formulations for protein and peptides by noninvasive routes. Lately, various approaches have been carried out which involve many strategies and technologies to deliver teriparatide via alternative routes. But, physicochemical instability, proteolytic degradation, low bioavailability, etc. are some obstacles to develop suitable delivery system for teriparatide. This review intends to gather the overall developments in delivery systems specific to teriparatide which meant for better convenience and avoids vulnerability of multiple subcutaneous injections. In addition, the article emphasizes on the successes to develop noninvasive technologies and devices, and new milestones for teriparatide delivery.

Predicting the acute-phase response fever risk in bisphosphonate-naive osteoporotic patients receiving their first dose of zoledronate

INTRODUCTION

To devise a precise and efficient tool for predicting the individualized risk of acute-phase response (APR) in bisphosphonate (BP)-naive osteoporotic (OP) patients, receiving their first intravenous dose of zoledronate (ZOL).

METHODS

The baseline clinical and laboratory data of 475 consecutive BP-naive OP patients, who received their first intravenous dose of ZOL between March 2016 and March 2021 in the Affiliated Kunshan Hospital of Jiangsu University, were chosen for analysis. Univariate and multivariable logistic regression models were generated to establish candidate predictors of APR fever risk, using three distinct fever thresholds, namely, 37.3 °C (model A), 38.0 °C (model B), and 38.5 °C (model C). Next, using predictor regression coefficients, three fever-threshold nomograms were developed. Discrimination, calibration, and clinical usefulness of each predicting models were then assessed using the area under the curve (AUC), calibration curve (CC), and decision curve analysis (DCA). The internal and external model validations were then performed.

RESULTS

The stable predictors were age, serum 25-hydroxy vitamin D, serum total calcium, and peripheral blood erythrocytes count. These were negatively associated with the APR fever risk. The AUCs of models A, B, and C were 0.828 (95% confidence intervals [CI], 0.782 to 0.874), 0.825 (95% CI, 0.767 to 0.883), and 0.879 (95% CI, 0.824 to 0.934), respectively. Good agreement was observed between the predictions and observations in the CCs of all three nomograms.

CONCLUSIONS

This study developed and validated nomogram prediction models that can predict APR fever risk in BP-naive OP patients receiving their first infusion of ZOL.

Triphasic calcium-based implant material resorbs and is replaced with bone in ovariectomized rats with or without bisphosphonate treatment

This study evaluated the effects of AGN1, a triphasic calcium-based material, and alendronate (A) on distal femoral defect bone repair in ovariectomized (OVX) rats. Of 106 rats, 92 were OVX'ed at 12 weeks old and underwent a 12-week induction period. Animals were randomized into five groups: OVX Control, OVX Alendronate Control, Normal Control, OVX Implantation, OVX Alendronate + Implantation. OVX Alendronate Control and OVX Alendronate + Implantation groups received alendronate injection twice weekly (0.015 mg/kg) from 6 weeks until sacrifice. Twelve weeks after OVX, 2.5 mm diameter by 4.0 mm long cylindrical, bilateral distal femoral defects were created in experimental animals. One defect was left empty, and one filled with AGN1. Dual-energy X-ray absorptiometry, microcomputed tomography, and histomorphometry were performed 0-, 6-, 12-, and 18-week postdefect/implantation surgery (N = 6-8/group). Results showed OVX induced significant and progressive bone loss which alendronate prevented. Histomorphometry demonstrated rapid AGN1 resorption: AGN1 resorbed from 95.1 ± 0.7% filling of the implant site (week 0) to 1.3 ± 1.0% (18 weeks) with no significant alendronate effect (1.6 ± 1.1%, 18 weeks). Bone formation in empty defects consisted primarily of cortical wall healing, whereas AGN1 implants demonstrated cortical wall healing with new trabecular bone filling the subcortical space. Alendronate dramatically increased bone formation in empty and AGN1 defects. We conclude AGN1 is resorbed and replaced by new cortical and trabecular bone in this OVX model, and alendronate did not compromise these effects.

Predicting the individualized risk of nonadherence to zoledronic acid among osteoporosis patients receiving the first infusion of zoledronic acid: development and validation of new predictive nomograms

Introduction:

Achieving optimal adherence to zoledronic acid (ZOL) among osteoporosis (OP) patients is a challenging task. Here, we aimed to develop and validate a precise and efficient prediction tool for ZOL nonadherence risk in OP patients.

Methods:

We prospectively collected and analyzed survey data from a clinical registry. A total of 1010 OP patients treated for the first time with ZOL in two separate hospitals were selected for nonadherence analysis. The evaluation included a 16-item ZOL Nonadherence Questionnaire and potential risk factors for ZOL nonadherence were assessed via univariate and multivariate analyses. We next developed and validated two distinct-stage nomograms. Discrimination, calibration, and clinical usefulness of the predicting models were assessed using the area under the curve (AUC), calibration curves, and decision curve analysis (DCA).

Results:

The total nonadherence rate was 20.30% after the first ZOL infusion. To generate a model predicting ZOL nonadherence risk, six predictors of 16 items were retained. Model 2 (AUC, 0.8486; 95% confidence interval [CI], 0.8171–0.8801) exhibited considerably more discrimination in desirable functional outcomes, relative to Model 1 (AUC, 0.7644; 95% CI, 0.7265–0.8024). The calibration curves displayed good calibration. DCA revealed that a cutoff probability of 5–54% (Model 1) and 1–85% (Model 2) indicated that the models were clinically useful. External validation also exhibited good discrimination and calibration.

Conclusions:

This study developed and validated two novel, distinct-stage prediction nomograms that precisely estimate nonadherence risk among OP patients receiving the first infusion of ZOL. However, additional evaluation and external validation are necessary prior to widespread implementation.

Insufficient persistence to pharmacotherapy in Japanese patients with osteoporosis: an analysis of the National Database of Health Insurance Claims and Specific Health Checkups in Japan

In Japan, persistence and the 2-year MPR were inadequate in increasing fracture control efficacy despite a high adherence rate during the treatment period. Both factors were higher in females and those with polypharmacy but worsened with increasing age.

PURPOSE

Only a few large-scale studies have examined the care gap between the patients who need osteoporosis treatment and those who receive them in Japan. The aim of this study was to investigate the persistence and adherence to osteoporosis pharmacotherapy in Japan.

METHODS

Continuation (persistence) rates and adherence to osteoporosis pharmacotherapy were investigated using medical insurance data from the National Database of Health Insurance Claims and Specific Health Checkups of Japan, between April 2012 and March 2019.

RESULTS

The study included 528,806 male and 3,064,410 female patients. Persistence proportions were 56.6% in the first year and 46.3% in the second year. The medication possession ratio (MPR) from start to discontinuation of treatment (MPR_discon) was 94.5%, and 92.7% of patients had an MPR_discon ≥ 80%. The 2-year MPR (MPR₇₃₀) was 61.9%, and 49.6% of patients had an MPR₇₃₀ ≥ 80%. Both the persistence proportion and MPR₇₃₀ were higher in females than in males, whereas MPR_discon was higher in males. The persistence proportion and MPR₇₃₀ were highest in the 70-79 years age group, whereas MPR_discon improved with increasing age. The MPR_discon and MPR₇₃₀ were higher in the mixed-fracture and vertebral-fracture groups, respectively. The persistence proportion, MPR_discon, and MPR₇₃₀ were higher in patients with polypharmacy than in those without.

CONCLUSION

In Japan, persistence and the 2-year MPR were inadequate in increasing fracture control efficacy despite a high adherence rate during the treatment period. To bridge the care gap following osteoporosis pharmacotherapy, improvements are required for males, the elderly, and those without polypharmacy.

Phase 1b Evaluation of Abaloparatide Solid Microstructured Transdermal System (Abaloparatide-sMTS) in Postmenopausal Women with Low Bone Mineral Density

BACKGROUND AND OBJECTIVE

Abaloparatide, an anabolic osteoporosis treatment administered by subcutaneous (SC) injection, increases bone mineral density (BMD) and reduces fracture risk in postmenopausal women with osteoporosis. The abaloparatide-solid Microstructured Transdermal System [abaloparatide-sMTS (Kindeva, St Paul, MN, USA)], which delivers abaloparatide intradermally, is in development to provide an alternative method for abaloparatide delivery. The objective of this study was to evaluate the ability of subjects to self-administer abaloparatide-sMTS, based on pharmacokinetic and pharmacodynamic markers.

METHODS

In this single-arm, open-label, Phase 1b study, 22 healthy postmenopausal women aged 50-85 years with low BMD were trained to self-administer abaloparatide-sMTS 300 μg once daily to the thigh for 5 min for 29 days. The primary endpoint was systemic exposure to abaloparatide. Secondary endpoints included percent change from baseline in serum procollagen type I N-terminal propeptide (s-PINP), patient experience, and safety.

RESULTS

All 22 subjects completed the study. At baseline, mean age was 65.2 years, mean total hip T-score was - 1.32, and mean lumbar spine T-score was - 1.98. On Day 1, the median time to reach maximum concentration (Tmax) for abaloparatide-sMTS was 0.33 h and geometric mean (CV %) maximum concentration (Cmax) and area under the concentration-time curve from time 0 to the time of the last quantifiable concentration (AUC0-t) were 447 (38.0) pg/mL and 678 (45.3) pg·h/mL, respectively; the pharmacokinetic profile was similar on Days 15 and 29. Median percentage change in s-PINP was 45.4% and 64.4% at Days 15 and 29, respectively. The most common adverse events (AEs) were application site erythema, pain, and swelling, which were mostly of mild or moderate severity. No AEs led to study drug withdrawal and no serious AEs were reported. The success rate for self-administration at first application was 99.7%, and subject acceptability was high (~ 4.5 on a 5-point Likert Scale).

CONCLUSIONS

Subjects successfully self-administered abaloparatide-sMTS, which provided a consistent pharmacokinetic profile over 29 days and produced s-PINP increases from baseline similar to that observed in the pivotal trial with abaloparatide-SC. Observed patient experience along with the clinical data support continued clinical development of abaloparatide-sMTS.

TRIAL REGISTRATION NUMBER

NCT04366726, Date of registration 04/29/2020, retrospectively registered.

Persistence and adherence to parenteral osteoporosis therapies: a systematic review

Osteoporosis is a chronic disease of low bone mass and fragility. Treatment is frequently compromised by suboptimal medication compliance causing increased morbidity. This review investigates adherence and persistence to parenteral osteoporosis therapies. Findings reveal parenteral medications requiring reduced dosing frequency have higher compliance than oral therapies. This systematic review examines real-world adherence to parenteral osteoporosis therapies. We searched PubMed, Medline, and EMBASE databases for English language observational studies that examined patient adherence and/or persistence to parenteral osteoporosis treatments (teriparatide sc, ibandronate iv, zoledronic acid iv, and denosumab sc) in adults with osteoporosis published up to September 2018. Studies with only self-reported adherence or persistence data and those with less than 20 patients were excluded. Quality assessment of included studies was completed using the Newcastle-Ottawa quality assessment scale (NOS). We identified 40 eligible studies. Teriparatide was examined in 29 studies, with persistence rates of 10-87% (median 55%) at 1 year and 10-69% (median 29.5%) at 2 years, and adherence rates of 21-89% (median 53%) at 1 year and 37-68% (median 40%) at 2 years. Ten studies of zoledronic acid reported persistence rates of 34-73% (median 42%) for second dose and 20-54% (median 35.8%) for third dose. Ten studies of ibandronate adherence reported and 2-year persistence rates of 31-58% (median 47.5%) in 1 year and 13-35% (median 25%) at 2 years, and adherence rates of 21-72% (median 47.3%) and 15-58% (median 36.5%) respectively. Denosumab was reported in 19 studies, with second (1 year) and fourth (2 year) dose persistence rates of 61-100% (median 81%) and 36-99% (median 45.5%). There is substantial heterogeneity in reports of persistence and adherence rates with parenteral osteoporosis therapies. Most of the published data are from short-term studies and evaluations of long-term adherence and persistence with parenteral therapies for osteoporosis are needed.

Group medical consultation for osteoporosis: a prospective pilot study of patient experience in Canadian tertiary care

BACKGROUND

Delivery of patient-centred care is limited by physician time. Group medical consultations may save physician time without compromising patient experience.

AIM

To assess patient experience and specialist physician time commitment in a group consultation for osteoporosis.

DESIGN AND SETTING

Prospective pilot study at a tertiary osteoporosis centre in Canada between May 2016 and June 2019.

METHOD

The authors evaluated women referred for osteoporosis who chose a 2-hour group consultation instead of a one-to-one consultation. Group consultations were led by an osteoporosis nurse and specialist physician, and consisted of individualised fracture risk assessment and education regarding osteoporosis therapies, followed by a decision-making exercise to choose a treatment plan. Patients then followed up with their GPs to implement this plan. Patient experience was assessed via a questionnaire immediately and 3 months post-consultation, at which time GP satisfaction and patient treatment status were also surveyed.

RESULTS

Of 560 referrals received, 18 patients declined osteoporosis specialist assessment, 54 could not be contacted, 303 attended a one-to- one consultation, and 185 attended a group consultation. Mean participant age was 62.8 years (standard deviation [SD] 5.8) and the Fracture Risk Assessment Tool (FRAX) 10-year osteoporotic fracture risk was 13.0 (SD 7.0)%. Immediately post-consultation, 104 (97.2%) patients were satisfied and 102 (95.3%) felt included in decision making. Satisfaction was reported by 95/99 (96.0%) patients and 27/36 (75.0%) GPs. Treatment plans had been enacted by 90 (90.1%) patients. For a matched number of individual consultations, each group session conferred a specialist physician time savings of 5.5 hours.

CONCLUSION

Group consultations represent a satisfactory and time-efficient alternative to one-to-one consultations for select patients with osteoporosis.

Delayed Denosumab Injections and Bone Mineral Density Response: An Electronic Health Record-based Study

CONTEXT

Discontinuation of denosumab leads to a rapid reversal of its therapeutic effect. However, there are no data regarding how unintended delays or missed injections of denosumab impact bone mineral density (BMD) response.

OBJECTIVE

We examined the association of delays in injections of denosumab with BMD change.

DESIGN

We used electronic medical records from two academic hospitals from 2010 to 2017.

PARTICIPANTS

Patients older than 45 years of age and used at least 2 doses of 60 mg denosumab. Denosumab adherence was evaluated by the medication coverage ratio (MCR). Good adherence corresponds to a dosing interval ≤7 months (defined by MCR ≥93%), moderate adherence corresponds to an interval of 7 to 10 months (MCR 75%-93%), and poor adherence corresponds to an interval ≥10 months (MCR ≤75%).

OUTCOME MEASURES

Annualized percent BMD change from baseline at the lumbar spine, total hip, and femoral neck.

RESULTS

We identified 938 denosumab injections among 151 patients; the mean (SD) age was 69 (10) years, and 95% were female. Patients with good adherence had an annualized BMD increase of 3.9% at the lumbar spine, compared with patients with moderate (3.0%) or poor adherence (1.4%, P for trend .002). Patients with good adherence had an annualized BMD increase of 2.1% at the total hip, compared with patients with moderate (1.3%) or poor adherence (0.6%, P for trend .002).

CONCLUSIONS

A longer interval between denosumab injections is associated with suboptimal BMD response at both spine and total hip. Strategies to improve the timely administration of denosumab in real-world settings are needed.

Adherence to and persistence with zoledronic acid treatment for osteoporosis-reasons for early discontinuation

This retrospective study reports 81% long-term (> 3 years) adherence to and 77% persistence with zoledronic acid (ZA) treatment in osteoporosis patients, with ZA being costfree for patients. Eight percent of patients discontinued treatment because of adverse events (AEs), with a tendency of higher discontinuation rate in older patients.

PURPOSE

This study investigated (1) long-term adherence to and persistence with ZA treatment in a real-world setting, (2) extent to which an adverse reaction to ZA impacted on adherence and persistence, and (3) whether there were sex or age differences in patients that had early treatment termination (ETT) due to AEs and those who adhered to the regimen.

METHODS

All patients treated with ZA at the Endocrinology Department at Linköping University Hospital, Linköping, Sweden between 2012 and 2017 were included. ETT was defined as < 3 ZA infusions, which was confirmed from patients' medical records.

RESULTS

A total of 414 patients were treated with ZA, with 81% receiving > 3 ZA infusions. Three-year persistence was 77% for a treatment window of 365 days ± 90 days (75% with 365 days ± 60 days window). The most common reason for ETT was AEs (8%), followed by medical conditions (5%), biological aging (3%), and other (e.g., lost to follow-up [3%]). Most patients who discontinued treatment because of AEs reported symptoms of acute-phase reaction, and tended to be older than those who adhered to treatment (74 ± 9 vs 70 ± 13 years, p = 0.064). There was no difference in sex ratio between the 2 groups (85% vs 90% females, p = 0.367).

CONCLUSION

Rates of long-term adherence to and persistence with ZA treatment were high with a pre-scheduled 3-year treatment regimen in the tax-financed Swedish healthcare system. AEs-mainly acute-phase reaction-were the most common reason for ETT, occurring in nearly 1 out of 10 patients.

At Odds About the Odds: Women's Choices to Accept Osteoporosis Medications Do Not Closely Agree with Physician-Set Treatment Thresholds

BACKGROUND

Osteoporosis guidelines recommend pharmacologic therapy based on 10-year risk of major osteoporotic fracture (MOF) and hip fracture, which may fail to account for patient-specific experiences and values.

OBJECTIVE

We aimed to determine whether patient decisions to initiate osteoporosis medication agree with guideline-recommended intervention thresholds.

DESIGN AND PARTICIPANTS

This prospective cohort study included women aged ≥ 45 with age-associated osteoporosis who attended a group osteoporosis self-management consultation at a tertiary osteoporosis center.

INTERVENTION

A group osteoporosis self-management consultation, during which participants received osteoporosis education and then calculated¹ their 10-year MOF and hip fracture risk using FRAX and² their predicted absolute fracture risk with therapy (assuming 40% relative reduction). Participants then made autonomous decisions regarding treatment initiation.

MAIN MEASURES

We evaluated agreement between treatment decisions and physician-set intervention thresholds (10-year MOF risk ≥ 20%, hip fracture risk ≥ 3%).

KEY RESULTS

Among 85 women (median [IQR] age 62 [58-67]), 27% accepted treatment (median [IQR] MOF risk, 15.1% [9.9-22.0]; hip fracture risk, 3.3% [1.3-5.3]), 46% declined (MOF risk, 9.5% [6.5-11.6]; hip fracture risk, 1.8% [0.6-2.3]), and 27% remained undecided (MOF risk, 14.0% [9.8-20.2]; hip fracture risk, 4.4% [1.7-4.9]). There was wide overlap in fracture risk between treatment acceptors and non-acceptors. Odds of accepting treatment were higher in women with prior fragility fracture (50% accepted; OR, 5.3; 95% CI, 1.9-15.2; p = 0.0015) and with hip fracture risk ≥ 3% (32% accepted; OR, 3.6; 95% CI, 1.4-9.2; p = 0.012), but not MOF risk ≥ 20% (47% accepted; OR, 3.0; 95% CI, 1.0-8.5; p = 0.105).

CONCLUSIONS

Informed decisions to start osteoporosis treatment are highly personal and not easily predicted using fracture risk. Guideline-recommended intervention thresholds may not permit sufficient consideration of patient preferences.

Zoledronate for the Prevention of Bone Loss in Women Discontinuing Denosumab Treatment. A Prospective 2-Year Clinical Trial

Cessation of denosumab treatment is associated with increases in bone turnover above baseline values and rapid bone loss. We investigated the efficacy of zoledronate to prevent this bone loss in women with postmenopausal osteoporosis who were treated with denosumab (mean duration 2.2 years) and discontinued treatment after achieving osteopenia. Women were randomized to receive a single 5-mg infusion of zoledronate (ZOL) (n = 27) or two additional 60-mg injections of denosumab (Dmab) (n = 30). Both groups were followed for a total period of 24 months. At 24 months lumbar spine-bone mineral density (LS-BMD) was not different from baseline in the ZOL group, but decreased in the Dmab group by (mean ± SD) 4.82% ± 0.7% (p < 0.001) from the 12-month value; the difference in BMD changes between the two groups, the primary endpoint of the study, was statistically significant (p = 0.025). Results of femoral neck (FN)-BMD changes were similar. ZOL infusion was followed by small but significant increases in serum procollagen type 1 N-terminal propeptide (P1NP) and C-terminal telopeptide of type 1 collagen (CTX) during the first year and stabilization thereafter. In the Dmab group, bone turnover marker values did not change during the first 12 months but increased significantly at 15 months and in the majority of women these remained elevated at 24 months. Neither baseline nor 12-month bone turnover marker values were associated with BMD changes in either group of women. In the Dmab group, three patients sustained vertebral fractures (two patients multiple clinical, one patient morphometric) whereas one patient in the ZOL group sustained clinical vertebral fractures 12 months after the infusion. In conclusion, a single intravenous infusion of ZOL given 6 months after the last Dmab injection prevents bone loss for at least 2 years independently of the rate of bone turnover. Follow-up is recommended, because in a few patients ZOL treatment might not have the expected effect at 2 years. © 2019 American Society for Bone and Mineral Research.

Hip fractures following denosumab discontinuation: three clinical cases reports

A significant loss of bone mineral density and the appearance of multiple vertebral fractures after discontinuation of denosumab treatment have been described. To date, no hip fractures have been reported. We present three cases of patients who suffered femoral fractures after denosumab suppression.

Two-year persistence with teriparatide improved significantly after introduction of an educational and motivational support program

This study evaluated the 2-year persistence with teriparatide in the Netherlands. Analyses showed that the risk of non-persistence was 28% lower in patients who were followed according to an additional educational and motivational support program.

INTRODUCTION

Until recently, teriparatide (TPTD) was a third-line treatment option for severe osteoporosis in the Netherlands, which could only be prescribed by medical specialists based on a specific medical statement. We aimed to determine whether an educational and motivational support program (EMSP) increased 2-year treatment persistence with TPTD in patients with severe osteoporosis.

METHODS

We evaluated persistence in 1573 Dutch patients treated with TPTD from January 2013 until January 2018. From January 2013 onwards, all patients received a basic support program (BSP) consisting of an educational home visit to initiate TPTD treatment and phone calls (at 1, 2.5 and 8 weeks). Since May 2015, all patients received the EMSP consisting of the BSP extended with evaluation of medication adherence during phone calls, an additional phone call (at 12 months), and motivational letters at 9 and 14 months.

RESULTS

The EMSP showed a statistically significantly higher 2-year persistence (78%) with TPTD as compared with the BSP (72%). Reasons for treatment discontinuation were comparable between groups, except for the proportion of patients who had stopped TPTD administration due to side effects, which was significantly lower in the EMSP group (8% vs. 15% in BSP, p < 0.001). Overall, the risk of non-persistence was 28% lower in the EMSP compared with the BSP group (HR: 0.72; 95% CI: 0.55-0.93).

CONCLUSION

The introduction of the EMSP has demonstrated to improve the persistence with TPTD, resulting in 78% of the patients being persistent with TPTD during the 2-year treatment period.

Reversal of Osteopenia in Ovariectomized Rats by Pentoxifylline: Evidence of Osteogenic and Osteo-Angiogenic Roles of the Drug

Pentoxifylline (PTX) is a non-selective phosphodiesterase inhibitor and is used for the management of intermittent claudication. We tested whether PTX has oral efficacy in stimulating new bone formation. Rat calvarial osteoblasts (RCO) were used to study the effect of PTX on osteoblast differentiation and angiogenesis. Pharmacokinetic and pharmacodynamic studies were carried out in rats to determine an oral dose of PTX. In ovariectomized (OVX) rats with osteopenia, the effect of PTX on various skeletal parameters was studied, and compared with teriparatide. Effect of PTX on angiogenic signaling was studied by immunoblotting and relevant pharmacologic inhibitors. Bone vascularity was measured by intravenous injection of polystyrene fluorospheres followed by in vivo imaging, and angiogenesis was studied in vitro by tubulogenesis of endothelial cells and in vivo by Matrigel plug assay. Effective concentration (EC₅₀) of PTX in RCO was 8.2 nM and plasma PTX level was 7 nM/mL after single oral dosing of 25 mg/kg, which was 1/6th the clinically used dose. At this dose, PTX enhanced bone regeneration at femur osteotomy site and completely restored bone mass, microarchitecture, and strength in OVX rats. Furthermore, PTX increased surface referent bone formation parameters and serum bone formation marker (PINP) without affecting the resorption marker (CTX-1). PTX increased the expression of vascular endothelial growth factor and its receptor in bones and osteoblasts. PTX also increased skeletal vascularity, tubulogenesis of endothelial cells and in vivo angiogenesis. Taken together, our study suggested that PTX at 16% of adult human oral dose completely reversed osteopenia in OVX rats by osteogenic and osteo-angiogenic mechanisms.

Long-term persistence in patients with osteoporosis receiving denosumab in routine practice: 36-month non-interventional, observational study

Persistence rates over 36 months with denosumab in patients diagnosed with osteoporosis in a real-world setting were examined, along with baseline patient characteristics predictive of persistence. This study represents the longest observational period with denosumab persistence and shows higher persistence rates when compared to bisphosphonates.

INTRODUCTION

The study objective was to describe long-term persistence with denosumab among patients treated for osteoporosis in a real-world setting. We also sought to examine patient characteristics predictive of persistence. Lastly, this study attempted to place the results in context by conducting a literature review of published persistence data for denosumab.

METHODS

This retrospective, non-interventional study analyzed 1158 patients from a specialty community private practice to assess patient persistence with denosumab in routine care. Persistence was defined as receiving seven denosumab injections, using an 8-week permissible gap, over 36 months. Non-persistent patients were further investigated retrospectively to identify reasons for discontinuation, when available.

RESULTS

Demographic analysis showed a population of 1158 patients with mean age 68.4 years old and baseline T-score - 2.7; nearly half of which experienced a prior osteoporosis-related fracture. In a Kaplan-Meier survival analysis, 36-month persistence overall was 50.7%. Net persistence, as defined by receiving seven injections in the allowable time frame, was 64.2% of the cohort. In a multivariate analysis, prior vertebral fractures and recent osteoporosis therapy were associated with higher persistence; age greater than 75 years was associated with non-persistence. Reasons for discontinuation were available in 91.6% of non-persistent patients and categorized to include the ten most common explanations.

CONCLUSION

This study to our knowledge represents the longest continuous observational period providing data on denosumab persistence in a real-world setting. The total persistence noted is quite robust when compared to bisphosphonates and is within the upper range of prior published studies of denosumab with shorter observation periods.

Nasal Administration and Plasma Pharmacokinetics of Parathyroid Hormone Peptide PTH 1-34 for the Treatment of Osteoporosis

Nasal delivery of large peptides such as parathyroid 1-34 (PTH 1-34) can benefit from a permeation enhancer to promote absorption across the nasal mucosa into the bloodstream. Previously, we have published an encouraging bioavailability (78%), relative to subcutaneous injection in a small animal preclinical model, for a liquid nasal spray formulation containing the permeation enhancer polyethylene glycol (15)-hydroxystearate (Solutol^® HS15). We report here the plasma pharmacokinetics of PTH 1-34 in healthy human volunteers receiving the liquid nasal spray formulation containing Solutol^® HS15. For comparison, data for a commercially manufactured teriparatide formulation delivered via subcutaneous injection pen are also presented. Tc-99m-DTPA gamma scintigraphy monitored the deposition of the nasal spray in the nasal cavity and clearance via the inferior meatus and nasopharynx. The 50% clearance time was 17.8 min (minimum 10.9, maximum 74.3 min). For PTH 1-34, mean plasma C_max of 5 pg/mL and 253 pg/mL were obtained for the nasal spray and subcutaneous injection respectively; relative bioavailability of the nasal spray was ≤1%. Subsequently, we investigated the pharmacokinetics of the liquid nasal spray formulation as well as a dry powder nasal formulation also containing Solutol^® HS15 in a crossover study in an established ovine model. In this preclinical model, the relative bioavailability of liquid and powder nasal formulations was 1.4% and 1.0% respectively. The absolute bioavailability of subcutaneously administered PTH 1-34 (mean 77%, range 55-108%) in sheep was in agreement with published human data for teriparatide (up to 95%). These findings have important implications in the search for alternative routes of administration of peptides for the treatment of osteoporosis, and in terms of improving translation from animal models to humans.

Oral dosing of pentoxifylline, a pan-phosphodiesterase inhibitor restores bone mass and quality in osteopenic rabbits by an osteogenic mechanism: A comparative study with human parathyroid hormone

The non-selective phosphodiesterase inhibitor pentoxifylline (PTX) is used for the treatment of intermittent claudication due to artery occlusion. Previous studies in rodents have reported salutary effects of the intraperitoneal administration of PTX in segmental bone defect and fracture healing, as well as stimulation of bone formation. We determined the effect of orally dosed PTX in skeletally mature ovariectomized (OVX) rabbits with osteopenia. The half-maximal effective concentration (EC₅₀) of PTX in rabbit bone marrow stromal cells was 3.07 ± 1.37 nM. The plasma PTX level was 2.05 ± 0.522 nM after a single oral dose of 12.5mg/kg, which was one-sixth of the adult human dose of PTX. Four months of daily oral dosing of PTX at 12.5 mg/kg to osteopenic rabbits completely restored bone mineral density, bone mineral content (BMC), microarchitecture and bone strength to the level of the sham-operated (ovary intact) group. The bone strength to BMC relationship between PTX and sham was similar. The bone restorative effect of PTX was observed in both axial and appendicular bones. In osteopenic rabbits, PTX increased serum amino-terminal propeptide, mineralized nodule formation by stromal cells and osteogenic gene expression in bone. PTX reversed decreased calcium weight percentage and poor crystal packing found in osteopenic rabbits. Furthermore, similar to parathyroid hormone (PTH), PTX had no effect on bone resorption. Taken together, our data show that PTX completely restored bone mass, bone strength and bone mineral properties by an anabolic mechanism. PTX has the potential to become an oral osteogenic drug for the treatment of post-menopausal osteoporosis.

In vitro injection of osteoporotic cadaveric femurs with a triphasic calcium-based implant confers immediate biomechanical integrity

Current pharmaceutical therapies can reduce hip fractures by up to 50%, but compliance to treatment is low and therapies take up to 18 months to reduce risk. Thus, alternative or complementary approaches to reduce the risk of hip fracture are needed. The AGN1 local osteo-enhancement procedure (LOEP) is one such alternative approach, as it is designed to locally replace bone lost due to osteoporosis and provide immediate biomechanical benefit. This in vitro study evaluated the initial biomechanical impact of this treatment on human cadaveric femurs. We obtained 45 pairs of cadaveric femurs from women aged 77.8 ± 8.8 years. One femur of each pair was treated, while the contralateral femur served as an untreated control. Treatment included debridement, irrigation/suction, and injection of a triphasic calcium-based implant (AGN1). Mechanical testing of the femora was performed in a sideways fall configuration 24 h after treatment. Of the 45 pairs, 4 had normal, 16 osteopenic, and 25 osteoporotic BMD T-scores. Altogether, treatment increased failure load on average by 20.5% (p < 0.0001). In the subset of osteoporotic femurs, treatment increased failure load by 26% and work to failure by 45% (p < 0.01 for both). Treatment did not significantly affect stiffness in any group. These findings provide evidence that local delivery of the triphasic calcium-based implant in the proximal femur is technically feasible and provides immediate biomechanical benefit. Our results provide strong rationale for additional studies investigating the utility of this approach for reducing the risk of hip fracture. © 2019 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society.

Stopping Denosumab

PURPOSE OF REVIEW

Denosumab discontinuation is associated with a rebound effect manifesting by an increased risk of multiple spontaneous vertebral fractures. The purpose of this review is to (1) better characterize this risk and (2) find solutions to avoid it.

RECENT FINDINGS

In the absence of a potent bisphosphonate prescription at denosumab discontinuation, the frequency of multiple vertebral fractures is common or frequent (≥ 1/100 and < 1/10). In five recent case series, the median number of vertebral fractures was 5 within 7 to 20 months (median 11) after the last denosumab injection. Prescribing bisphosphonate before starting denosumab and/or after stopping denosumab may reduce this risk. However, only small case series have evaluated these strategies. After the second denosumab dose, there is a rebound effect with an increased risk of multiple vertebral fractures. A potent bisphosphonate prescribed at denosumab discontinuation could reduce this risk. As denosumab discontinuation is characterized by many uncertainties, denosumab is a second-line treatment for osteoporosis. Studies are urgently needed to define the management of denosumab discontinuation.

Antiresorptive agents' bone-protective and adjuvant effects in postmenopausal women with early breast cancer

Potent antiresorptive drugs (bisphosphonate and denosumab) are often used to protect bone health in postmenopausal breast cancer patients. In addition, clinical trials have shown that these drugs increase disease-free survival, though the mechanism of adjuvant benefit is largely unknown. Here we review the bone health and adjuvant data for both classes of antiresorptive drugs and highlight differences in their pharmacology. Inhibition of bone resorption is vitally important to protect against osteoporotic fractures, and may also contribute to adjuvant survival benefits by making the bone microenvironment less amenable to breast cancer metastasis. After a course of therapy, stoppage of bisphosphonates yields a persistent antiresorptive effect, whereas discontinuation of denosumab causes a rebound increase in bone resorption markers and a loss of bone mineral density to baseline levels. Whether the potential adjuvant benefits of denosumab are also rapidly lost after drug discontinuation deserves further investigation.

Cost-Effectiveness of Pharmacological Treatments for Osteoporosis Consistent with the Revised Economic Evaluation Guidelines for Canada

Introduction. Given the lack of independent analyses comparing numerous pharmacotherapies for osteoporosis, the study objective was to identify the optimal osteoporosis treatment based on a woman's age, fracture history, and ability to tolerate oral bisphosphonates adopting practices recommended in the recently revised Canadian guidelines. Methods. A cost utility analysis from the health care system perspective compared alendronate, etidronate, risedronate, zoledronate, denosumab, and no pharmacotherapy using a Markov model incorporating data on fracture risk and their associated costs, mortality, and disutility and treatment effect. Stratified analysis was conducted based on age, fracture history, and ability to tolerate oral bisphosphonates. Expected lifetime outcomes were obtained through probabilistic analysis with scenario analyses addressing methodological and structural uncertainty. Results. For women able to tolerate oral bisphosphonates, risedronate and etidronate were dominated. Compared to no therapy, alendronate was either dominant or was associated with a low incremental cost per QALY (quality-adjusted life years) gained (ICER)-less than CAN$3,751 based on age and fracture history. In comparison with alendronate, both zoledronate and denosumab were either dominated or associated with a high ICER-greater than CAN$660,000 per QALY. For women unable to tolerate bisphosphonates, dependent on age and fracture history, the ICER for zoledronate versus no therapy ranged from CAN$17,770 to CAN$94,365 per QALY. For all strata, denosumab was dominated by zoledronate or had an ICER greater than CAN$3.0 million. Scenario analyses found consistent findings. Conclusions. Based on a threshold of CAN$50,000 per QALY, alendronate is optimal for osteoporotic women who can tolerate oral bisphosphonates regardless of age or fracture history. For women unable to tolerate oral bisphosphonates, zoledronate is optimal for women with previous fracture or aged 80 to 84 or over 90 with no previous fracture.

Discontinuation of Denosumab therapy for osteoporosis: A systematic review and position statement by ECTS

INTRODUCTION

The optimal duration of osteoporosis treatment is controversial. As opposed to bisphosphonates, denosumab does not incorporate into bone matrix and bone turnover is not suppressed after its cessation. Recent reports imply that denosumab discontinuation may lead to an increased risk of multiple vertebral fractures.

METHODS

The European Calcified Tissue Society (ECTS) formed a working group to perform a systematic review of existing literature on the effects of stopping denosumab and provide advice on management.

RESULTS

Data from phase 2 and 3 clinical trials underscore a rapid decrease of bone mineral density (BMD) and a steep increase in bone turnover markers (BTMs) after discontinuation of denosumab. Clinical case series report multiple vertebral fractures after discontinuation of denosumab and a renewed analysis of FREEDOM and FREEDOM Extension Trial suggests, albeit does not prove, that the risk of multiple vertebral fractures may be increased when denosumab is stopped due to a rebound increase in bone resorption.

CONCLUSION

There appears to be an increased risk of multiple vertebral fractures after discontinuation of denosumab although strong evidence for such an effect and for measures to prevent the occurring bone loss is lacking. Clinicians and patients should be aware of this potential risk. Based on available data, a re-evaluation should be performed after 5years of denosumab treatment. Patients considered at high fracture risk should either continue denosumab therapy for up to 10years or be switched to an alternative treatment. For patients at low risk, a decision to discontinue denosumab could be made after 5years, but bisphosphonate therapy should be considered to reduce or prevent the rebound increase in bone turnover. However, since the optimal bisphosphonate regimen post-denosumab is currently unknown continuation of denosumab can also be considered until results from ongoing trials become available. Based on current data, denosumab should not be stopped without considering alternative treatment in order to prevent rapid BMD loss and a potential rebound in vertebral fracture risk.

Denosumab for the treatment of osteoporosis

Denosumab, a specific inhibitor of RANK ligand, is a novel therapy for postmenopausal osteoporosis and related disorders. An extensive clinical development program has evaluated the clinical efficacy and safety of denosumab with several thousand patients being followed for up to 10 years. Combined with more than six years of postmarketing experience, these studies provide substantial confidence that denosumab is a convenient and appropriate treatment for patients, including Asians, at high risk for fracture. This review will summarize the clinical development of denosumab and lessons learned since its approval for clinical use in 2010.