Treatment Effects of Bisphosphonates and Denosumab on Survival and Refracture from Real-World Data of Hip-Fractured Patients

Sentinel fracture: the necessity of improved post-fracture care

Fragility fractures caused by osteoporosis, the most common metabolic bone disease, place a significant burden on affected individuals and impose substantial economic costs. A fragility fracture implies an imminent elevated risk for subsequent fractures, particularly in the short term. Therefore, osteoporosis must be addressed in the event of a sentinel fracture, if not already previously treated. Regardless of whether the fracture is treated conservatively or surgically, post-fracture care is particularly important. Early mobilization followed by fall risk assessment and the initiation of adequate bone-specific medication are essential milestones in preventing subsequent fractures. Monitoring patients increases adherence to bone-specific medication and fall prevention strategies. Comprehensive post-fracture care is important and should be performed by a multidisciplinary team. Coordinated care models, such as the fracture liaison service (FLS), have shown enhancements in the initiation of and adherence to secondary prevention of fragility fractures. Despite recommendations by several guidelines including that published by the Austrian Society for Bone and Mineral Research, only one fracture liaison service has been implemented in Austria.

Opportunistic Identification of Vertebral Compression Fractures on CT Scans of the Chest and Abdomen, Using an AI Algorithm, in a Real-Life Setting

This study evaluated the performance of a vertebral fracture detection algorithm (HealthVCF) in a real-life setting and assessed the impact on treatment and diagnostic workflow. HealthVCF was used to identify moderate and severe vertebral compression fractures (VCF) at a Danish hospital. Around 10,000 CT scans were processed by the HealthVCF and CT scans positive for VCF formed both the baseline and 6-months follow-up cohort. To determine performance of the algorithm 1000 CT scans were evaluated by specialized radiographers to determine performance of the algorithm. Sensitivity was 0.68 (CI 0.581-0.776) and specificity 0.91 (CI 0.89-0.928). At 6-months follow-up, 18% of the 538 patients in the retrospective cohort were dead, 78 patients had been referred for a DXA scan, while 25 patients had been diagnosed with osteoporosis. A higher mortality rate was seen in patients not known with osteoporosis at baseline compared to patients known with osteoporosis at baseline, 12.8% versus 22.6% (p = 0.003). Patients receiving bisphosphonates had a lower mortality rate (9.6%) compared to the rest of the population (20.9%) (p = 0.003). HealthVCF demonstrated a poorer performance than expected, and the tested version is not generalizable to the Danish population. Based on its specificity, the HealthVCF can be used as a tool to prioritize resources in opportunistic identification of VCF's. Implementing such a tool on its own only resulted in a small number of new diagnoses of osteoporosis and referrals to DXA scans during a 6-month follow-up period. To increase efficiency, the HealthVCF should be integrated with Fracture Liaison Services (FLS).

Mortality and re-fracture rates in low trauma hip fracture

OBJECTIVES

This study aimed to estimate the incidence rate of re-fracture and all-cause mortality rate in patients with hip fractures caused by minor trauma in the first year following the event.

MATERIALS AND METHODS

This is a retrospective cohort study of patients over 50 years of age conducted in a referral hospital located in Tehran (Shafa-Yahyaian). Using the hospital information system (HIS), all patients hospitalized due to hip fractures caused by minor trauma during 2013-2019 were included in the study. We investigated the occurrence of death and re-fracture in all patients one year after the primary hip fracture.

RESULTS

A total of 945 patients with hip fractures during a 307,595 person-days of follow-up, were included. The mean age of the participants was 71 years (SD = 11.19), and 533 (59%) of them were women. One hundred forty-nine deaths were identified during the first year after hip fracture, resulting in a one-year mortality rate of 17.69% (95% CI: 15.06-20.77). The one-year mortality rate was 20.06% in men and 15.88% in women. Out of all the participants, 667 answered the phone call, of which 29 cases had experienced a re-fracture in the first year (incidence rate = 5.03%, 95% CI: 3.50-7.24). The incidence rates in women and men were 6.07% and 3.65%, respectively.

CONCLUSION

Patients with low-trauma hip fractures have shown a high rate of mortality in the first year. Considering the increase in the incidence of hip fractures with age, comprehensive strategies are needed to prevent fractures caused by minor trauma in the elderly population.

Perspectives on Fracture Liaison Service in Austria: clinical and economic considerations

Osteoporosis is a widespread disease and affects over 500,000 people in Austria. Fragility fractures are associated with it and represent not only an individual problem for the patients, but also an enormous burden for the healthcare system. While trauma surgery care is well provided in Vienna, there is an enormous treatment gap in secondary prevention after osteoporotic fracture. Systematic approaches such as the Fracture Liaison Service (FLS) aim to identify patients with osteoporosis after fracture, to clarify diagnostically, to initiate specific therapy, and to check therapy adherence. The aim of this article is to describe the practical implementation and operational flow of an already established FLS in Vienna. This includes the identification of potential FLS inpatients, the diagnostic workup, and recommendations for an IT solution for baseline assessment and follow-up of FLS patients. We summarize the concept, benefits, and limitations of FLS and provide prospective as well as clinical and economic considerations for a city-wide FLS, managed from a central location. Future concepts of FLS should include artificial intelligence for vertebral fracture detection and simple IT tools for the implementation of FLS in the outpatient sector.

Denosumab and Mortality in a Real-World Setting: A Comparative Study

Denosumab (Dmab) is increasingly prescribed worldwide. Unlike bisphosphonates (BPs), its effect on mortality has yet to be well explored. This study examined the association between Dmab and all-cause mortality compared with no treatment in subjects with a fracture and BPs in subjects without a fracture. The study population was from the Sax Institute's 45 and Up Study (n = 267,357), a prospective population-based cohort with questionnaire data linked to hospital admissions (Admitted Patients Data Collection [APDC] data were linked by the Centre for Health Record Linkage), medication records (Pharmaceutical Benefits Scheme [PBS] provided by Services Australia), and stored securely (secure data access was provided through the Sax Institute's Secure Unified Research Environment [SURE]). The new-user cohort design with propensity-score (PS) matching was implemented. In the fracture cohort, Dmab and oral BP users were matched 1:2 to no treatment (Dmab: 617 women, 154 men; oral BPs: 615 women, 266 men). In the no-fracture cohort, Dmab users were matched 1:1 with oral BPs and zoledronic acid (Zol) users (Dmab:oral BPs: 479 men, 1534 women; Dmab:Zol: 280 men, 625 women). Mortality risk was measured using sex-specific pairwise multivariable Cox models. In the fracture cohort, compared with no treatment, Dmab was associated with 48% lower mortality in women (hazard ratio [HR] = 0.52, 95% confidence interval [CI] 0.36-0.72) but not in men. Oral BPs were associated with 44% lower mortality in both sexes (women HR = 0.56, 95% CI 0.42-0.77; men HR = 0.56, 95% CI 0.40-0.78). In the no-fracture cohort, compared with BPs, Dmab was associated with 1.5- to 2.5-fold higher mortality than oral BPs (women HR = 1.49, 95% CI 1.13-1.98; men HR = 2.74; 95% CI 1.82-4.11) but similar mortality to Zol. Dmab in women and oral BPs were associated with lower post-fracture mortality than no treatment. However, Dmab users had generally higher mortality than oral BP users in those without fractures. © 2023 American Society for Bone and Mineral Research (ASBMR).

Antiresorptive Medication Use Is not Associated With Acute Cardiovascular Risk: An Observational Study

CONTEXT

Bisphosphonates have been reported to be cardioprotective in some, but not all, studies. It is unknown whether denosumab (Dmab) use protects against cardiovascular events (CVEs).

OBJECTIVE

To determine whether oral bisphosphonate (oBP) or Dmab use is associated with CVEs in persons with incident fracture.

METHODS

Participants with an incident minimal trauma fracture from the Sax Institute's 45 and Up Study, a population-based cohort from NSW, Australia, were followed between 2005/2009 and 2017. Questionnaire data were linked to hospital admissions (Admitted Patients Data Collection [APDC]) by the Centre for Health Record Linkage). Medicare Benefit Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data sets were provided by Services Australia. Data was stored in a secure computing environment (Secure Unified Research Environment). Fractures, CVEs, and comorbidities were identified from the APDC and oBP and Dmab medication from the PBS. oBP and Dmab users were matched to never users (NoRx) by propensity scores. The main outcome measures were association between oBP and Dmab with CVE (acute myocardial infarction, unstable angina, cerebrovascular accident, and transient ischemic attack) and were determined using a stratified Cox's proportional hazards model.

RESULTS

There were 880 pairs of oBP and NoRx (616 women) and 770 pairs of Dmab and NoRx (615 women) followed for ∼4.3 years. CVE risk was similar for oBP and NoRx Hazard Ratios (HR) women, 0.88 [95% CI 0.65-1.18]; men, 1.07 [95% CI 0.72-1.57]). Similar findings were obtained for Dmab (Hazard Ratios (HR) women, 1.08 [95% CI 0.78-1.50]; men, 1.55 [95% CI 0.96-2.48]).

CONCLUSION

oBP and Dmab use was not associated with CVEs.

Bone Turnover Markers Including Undercarboxylated Osteocalcin Are Associated With Mortality Risk in Older Men

Osteocalcin in its undercarboxylated form (ucOC) may influence diabetes risk; however, its relationship with all-cause and cause-specific mortality is unclear. Whether other bone turnover markers (BTMs) are associated with mortality risk differently from ucOC also remains uncertain. Our aim was to determine associations of serum ucOC with all-cause and cause-specific mortality and compare these with the corresponding associations of serum total osteocalcin (TOC), procollagen type I N-propeptide (PINP), and collagen type 1 C-terminal cross-linked telopeptide (CTX) in older men. We conducted a prospective cohort study of 3871 community-dwelling men, aged 77.0 ± 3.6 years at baseline, followed for a median of 12.3 years. Exposure variables were ucOC, TOC, PINP, and CTX concentrations assayed in serum. Outcomes were incidence of all deaths and deaths due to cardiovascular disease (CVD) or cancer, ascertained using death registry data. Cox regression analyses adjusted for cardiovascular risk factors and prevalent CVD and for prevalent cancer in analyses of cancer-related mortality. Higher concentrations of ucOC, PINP, and CTX were associated with all-cause mortality (hazard ratio [HR] per 1 standard deviation increase: ucOC 1.12, 95% confidence interval [CI] 1.06-1.18, p < 0.001; PINP HR = 1.06, 95% CI 1.01-1.11, p = 0.009; CTX HR = 1.13, 95% CI 1.08-1.19, p < 0.001), but TOC was not associated. Similar results were found after excluding men with an incident fracture during follow-up. Higher ucOC and CTX were associated with CVD mortality (ucOC HR per 1 SD increase 1.13, 95% CI 1.05-1.22, p = 0.001; CTX HR = 1.12, 95% CI 1.04-1.20, p = 0.003), but this result was not significant in competing risks analysis. Higher CTX was also associated with cancer mortality (HR = 1.12, 95% CI 1.01-1.23, p = 0.024). In conclusion, in older men, higher bone turnover, assessed by BTMs including ucOC, is a biomarker for all-cause mortality risk. Undercarboxylated osteocalcin was a more informative biomarker for this outcome than TOC. Higher CTX was associated with all-cause and cancer-related mortality. Further evaluation of causality and potential underlying mechanisms is warranted. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Reduced All-Cause Mortality with Bisphosphonates Among Post-Fracture Osteoporosis Patients: A Nationwide Study and Systematic Review

We assessed the survival outcomes associated with real-world bisphosphonate use, stratified by fracture site, type, administration, and duration of treatment, among patients with osteoporosis. A systematic review that incorporates our findings was conducted to provide up-to-date evidence on survival outcomes with bisphosphonate treatment in real-world settings. Patients diagnosed with osteoporosis who had been hospitalized for major fractures were identified from Taiwan's National Health Insurance Research Database 2008-2017 and followed until 2018. There were 24,390 new bisphosphonate users who were classified and compared with 76,725 nonusers of anti-osteoporosis medications in terms of survival outcomes using Cox model analysis. An inverse probability of treatment weighted Cox model and landmark analyses for minimizing immortal time bias were also performed. Bisphosphonate users vs. nonusers had a significantly lower mortality risk, regardless of fracture site (hazard ratios (95% confidence intervals) for patients with any major fracture, hip fracture, and vertebral fracture: 0.90 (0.88, 0.93), 0.83 (0.80, 0.86), and 0.86 (0.82, 0.89), respectively). Compared with nonuse, zoledronic acid (0.77 (0.73, 0.82)) was associated with the lowest mortality, followed by ibandronate (0.85 (0.78, 0.93)) and alendronate/risedronate (0.93 (0.91, 0.96)). Using bisphosphonates for ≥ 3 years had lower mortality (0.60 (0.53, 0.67)) than using bisphosphonates for < 3 years (0.98 (0.95, 1.01)). Intravenous bisphosphonates had a lower mortality than that of oral bisphosphonates. Our results are consistent with the systematic review findings among real-world populations. In conclusion, bisphosphonate use, especially persistence to intravenous bisphosphonates (e.g., zoledronic acid), may reduce post-fracture mortality among patients with osteoporosis, particularly those with hip/vertebral fractures. This supports the rational use of bisphosphonates in post-fracture care.

Association Between Osteoporosis and Refracture Rate Among Patients With Hip Fractures at King Abdulaziz Medical City, Saudi Arabia

Background

Hip fracture is a major medical and surgical topic and is a significant cause of morbidity and mortality. Older women, especially those with osteoporosis, are at an increased risk for hip fractures. Multiple studies have shown the effect of osteoporosis on the refracture rate among the elderly population. Therefore, selecting a targeted population for screening and treating osteoporosis has an essential role in decreasing the hip fracture rate. This study aimed to determine the association between osteoporosis treatment and refracture rate among patients with hip fractures at King Abdulaziz Medical City, Jeddah, Saudi Arabia.

Methods

Collected data included patient demographics (men: ≥55 years old; women: ≥50 years old), the used osteoporosis investigation method, osteoporosis treatment history, presence of comorbidities, and refracture as a primary outcome. The refracture rate among patients with hip fracture was calculated and used to determine the association between hip refracture and osteoporosis.

Results

Our study included a total of 292 patients who presented to our hospital due to hip fractures. The patients were divided into two groups, the osteoporotic and non-osteoporotic groups. These groups were then compared. There was no statistical significance between osteoporosis and hip refracture (p = 0.721), and there was no association between the treatment of osteoporosis and hip refracture (p = 0.493). Statistical difference was found between patients who had undergone dual-energy X-ray absorptiometry scan and were not treated for osteoporosis (p = 0.00). Lastly, the mortality of the refracture group was 10%, while it was 11% in the no-refracture group (p = 1.00).

Conclusion

Morbidity and mortality rates are higher among patients with hip fractures. Our study showed that there was no association between hip refracture rate and osteoporosis whether the patient is treated for osteoporosis or not. We recommend a systematic review that can include more studies in this field to acquire more definitive results regarding this topic.

Kidney Function Change and All-Cause Mortality in Denosumab Users with and without Chronic Kidney Disease

Denosumab is approved for osteoporosis treatment in subjects with and without chronic kidney disease (CKD). Confirmation is required for its safety, treatment adherence, renal function effect, and mortality in patients with CKD. A retrospective cohort study was conducted to compare new users of denosumab in terms of their two-year drug adherence in all participants (overall cohort) and CKD participants (CKD subcohort), which was defined as baseline estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2. The eGFR was calculated using the 2021 CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation. We defined high adherence (HA) users as receiving three or four doses and low adherence (LA) users as receiving one or two doses. All-cause mortality was analyzed using Kaplan-Meier curves and Cox regression models. In total, there were 1142 subjects in the overall cohort and 500 subjects in the CKD subcohort. HA users had better renal function status at baseline than LD users in the overall cohort. A decline in renal function was only observed among LD users in the overall cohort. In the CKD subcohort, no baseline renal function difference or renal function decline was demonstrated. The all-cause mortality rate of HA users was lower than LA users in both the overall cohort and CKD. A randomized control trial is warranted to target this unique population to confirm our observations.

Age-related alterations and senescence of mesenchymal stromal cells: Implications for regenerative treatments of bones and joints

The most common clinical manifestations of age-related musculoskeletal degeneration are osteoarthritis and osteoporosis, and these represent an enormous burden on modern society. Mesenchymal stromal cells (MSCs) have pivotal roles in musculoskeletal tissue development. In adult organisms, MSCs retain their ability to regenerate tissues following bone fractures, articular cartilage injuries, and other traumatic injuries of connective tissue. However, their remarkable regenerative ability appears to be impaired through aging, and in particular in age-related diseases of bones and joints. Here, we review age-related alterations of MSCs in musculoskeletal tissues, and address the underlying mechanisms of aging and senescence of MSCs. Furthermore, we focus on the properties of MSCs in osteoarthritis and osteoporosis, and how their changes contribute to onset and progression of these disorders. Finally, we consider current treatments that exploit the enormous potential of MSCs for tissue regeneration, as well as for innovative cell-free extracellular-vesicle-based and anti-aging treatment approaches.

Adherence to Anti-Osteoporotic Treatment and Clinical Implications after Hip Fracture: A Systematic Review

The role of anti-osteoporotic treatment as part of the secondary prevention after hip fracture in terms of mortality and re-fracture risk has been studied, and the results are promising. Decreased treatment adherence and compliance is a problem that needs to be addressed by healthcare professionals. A systematic review of the literature was performed using the PubMed database with terms that included hip fracture, mortality, second fracture, and specific anti-osteoporotic treatment. We included 28 articles, 21 regarding mortality and 20 re-fracture rates in hip fracture patients. All studies showed lower mortality after hip fracture associated with anti-osteoporotic treatment, mostly bisphosphonate agents. The re-fracture risk is still debatable, since conflicting data were found. Although most of the studies showed notable effects on mortality and re-fracture rates associated with anti-osteoporotic treatment, we still need more data to validate the actual results.

Bisphosphonates and lifespan

Bisphosphonates are first line agents used to treat osteoporosis and reduce fracture rate. They bind to areas of exposed calcium in the skeleton and cause osteoclast apoptosis, thereby leading to a reduction in remodelling rates. They are also used to decrease skeletal complications of some cancers including a reduction in bone metastases. Following the landmark randomised controlled trial of zoledronate post hip fracture (HORIZON) in which an unexpected survival benefit was found, there has been increasing interest in their potential ability to increase lifespan. This review will consider the clinical evidence for their effect on mortality in both the osteoporosis and non-osteoporosis settings, the latter including studies in intensive care, cancer and cardiovascular disease. Where evidence exists, this review will briefly discuss some of the postulated mechanisms for this survival benefit.

A Review on the Role of Denosumab in Fracture Prevention

Denosumab is a receptor activator of nuclear factor kappa-Β ligand inhibitor, which suppresses the bone resorption process to preserve bone mass. It is usually recommended to postmenopausal women and men with high fracture risk. With the recent publication of the results from FREEDOM study and its extension, the long-term effect of denosumab in preventing fragility fractures has been put forward. This review aims at summarising the evidence of denosumab in reducing fracture risk and its safety derived from clinical studies. Most of the evidence are derived from FREEDOM trials up to 10 years of exposure. Denosumab is reported to prevent vertebral and non-vertebral fractures. It is also proven effective in Japanese women, patients with chronic kidney diseases and breast cancer patients receiving antineoplastic therapy. Denosumab discontinuation leads to high remodeling, loss of bone mineral density and increased fracture risk. These negative effects might be preventable by bisphosphonate treatment. The safety profile of denosumab is consistent with increased years of exposure. In conclusion, denosumab is a safe and effective option for reducing fracture risk among patients with osteoporosis.

Osteoporosis Therapeutics 2020

Numerous safe and efficient drug therapies are currently available to decrease risk of low trauma fractures in patients with osteoporosis including postmenopausal, male, and secondary osteoporosis. In this chapter, we give first an overview of the most important outcomes regarding fracture risk reduction, change in bone mineral density (BMD by DXA) and/or bone markers of the phase III clinical studies of well-established therapies (such as Bisphosphonates, Denosumab or Teriparatide) and also novel therapies (such as Romosozumab or Abaloparatide) and highlight their mechanisms of action at bone tissue/material level. The latter understanding is not only essential for the choice of drug, duration and discontinuation of treatment but also for the interpretation of the clinical outcomes (in particular of eventual changes in BMD) after drug administration. In the second part of this chapter, we focus on the management of different forms of osteoporosis and give a review of the respective current guidelines for treatment. Adverse effects of treatment such as atypical femoral fractures, osteonecrosis of the jaw or influence of fracture healing are considered also in this context.