Medical specialty-related adherence to anti-osteoporotic regimens in fragility hip fracture patients

Treatment of osteoporosis after hip fracture is associated with lower all-cause mortality: A nationwide population study

PURPOSE

Mortality after osteoporotic hip fractures is high. Postoperative care is as important as surgery itself to prevent a second fracture and improve outcomes, and the effect of anti-osteoporosis treatment after hip fractures on overall mortality is controversial. This nationwide population study aimed to determine whether anti-osteoporosis treatment might reduce overall mortality after hip fracture surgery.

METHODS

We conducted this cohort study using the National Health Insurance Research Database (NHIRD) of Taiwan to identify patients admitted for surgery due to hip fractures from 2008 to 2018. The subsequent use and duration of anti-osteoporotic medication and other parameters were analyzed, and national death registration records were retrieved to investigate mortality.

RESULTS

A total of 59,943 patients admitted for hip fracture surgery were identified. The 22,494 patients (37.5%) who received anti-osteoporotic medication showed a lower all-cause mortality rate compared with the 37,449 patients (62.5%) who did not receive further treatment (hazard ratio (HR): 0.69, 95% confidence interval (CI): 0.67-0.70, p < 0.0001). Patients who received anti-osteoporotic medication for more than 1, 2, and 3 years exhibited propotional reductions in all-cause mortality (HR & 95%CI: 0.57 (0.54-0.60), 0.42 (0.38-0.46), and 0.29 (0.26-0.33) respectively).

CONCLUSION

Anti-osteoporosis treatment was associated with lower all-cause mortality after hip fracture surgery. A longer duration of treatment was also associated with lower mortality. Postoperative treatment for osteoporosis is crucial for patients with hip fracture.

Romosozumab or alendronate for fracture prevention in East Asian patients: a subanalysis of the phase III, randomized ARCH study

Romosozumab, a sclerostin antibody, exerts dual effect to increase bone formation and decrease bone resorption. Among high-risk postmenopausal East Asian women, romosozumab followed by alendronate was associated with lower incidences of fractures vs alendronate alone. Romosozumab demonstrates potential to address an unmet need in osteoporosis management in Asia.

INTRODUCTION

Romosozumab, a sclerostin antibody, exerts dual effect to increase bone formation and decrease bone resorption. The global ARCH study demonstrated superiority of romosozumab followed by alendronate in reducing fracture risk in high-risk postmenopausal osteoporotic women vs alendronate alone. We report outcomes among ARCH East Asian patients.

METHODS

In ARCH, 4093 postmenopausal osteoporotic women with fragility fracture were randomized 1:1 to monthly romosozumab 210 mg or weekly alendronate 70 mg for 12 months, both followed by open-label alendronate. Primary endpoints were incidence of new vertebral fracture (VF) at 24 months and clinical fracture at primary analysis (confirmed fractures in ≥ 330 patients and all patients had opportunity to attend month 24 visit). This post hoc analysis was not powered to detect fracture-rate differences.

RESULTS

This analysis included 275 patients from Hong Kong, Korea, and Taiwan. Romosozumab followed by alendronate reduced risk of new VFs at 24 months by 60% (P = 0.11) and clinical fractures at primary analysis by 44% (P = 0.15) vs alendronate alone. Romosozumab followed by alendronate significantly increased mean bone mineral density at 24 months from baseline by a further 9.0%, 3.3%, and 3.0% at the lumbar spine, total hip, and femoral neck vs alendronate alone. Adverse event (AE) rates, including positively adjudicated serious cardiovascular AEs (1.6% vs 1.4% at 12 months for romosozumab vs alendronate), were similar across treatment groups.

CONCLUSIONS

Consistent with the global analysis, romosozumab followed by alendronate was associated with lower incidences of new vertebral, clinical, non-vertebral, and hip fractures vs alendronate alone among East Asian patients.

A national study on long-term osteoporosis therapy and risk of recurrent fractures in patients with hip fracture

OBJECTIVE

The study aimed to evaluate the impact of osteoporosis (OP) medication persistence on subsequent fractures and all-cause mortality in patients with hip fracture.

METHODS

In this retrospective cohort study, we included patients aged ≥ 40 years with fragility hip fracture from the Taiwan's National Health Insurance Research Database. OP medication persistence was categorized as yes (≥ 12 months) or no (< 12 months). A multivariate Cox proportional hazard model was used to evaluate the association between OP medication persistence and recurrent fractures (including hip, vertebral, and upper and lower limb fractures) and all-cause mortality.

RESULTS

A total of 946 patients were included in the study (86.5 % of them aged ≥ 65 years) and 210 patients persistently received OP medications. Persistent OP medication use was associated with lower fracture risk (adjusted hazard ratio [aHR] = 0.64; 95 % CI = 0.41-0.99; P = .043) in the follow-up period. The strongest predictors for all-cause mortality were age ≥ 80 years (HR = 5.68, 95 % CI = 1.36-23.64, P = .017), male sex (HR = 1.55; 95 % CI = 1.18-2.03; P = .002), and Charlson Comorbidity Index ≥ 3 (aHR = 1.56; 95 % CI = 1.07-2.27; P = .022). Kaplan-Meier curves showed a lower cumulative incidence of recurrent fractures in the persistent group than that in the non-persistent group (P = .028).

CONCLUSION

Persistent OP medication use was associated with a lower risk of recurrent fractures but not with mortality in patients with hip fracture.

Patient and Perioperative Factors Influencing the Functional Outcomes and Mortality in Elderly Hip Fractures

This study aimed to evaluate the functional outcomes and mortality following hip fracture surgery in elderly patients, and to identify the associated risk factors. Between January 2016 and December 2017, 480 consecutive patients were finally included for data analyses. The Harris score and Barthel index were used to evaluate the hip function and ability to perform activities of daily living (ADL). Univariate and multivariate logistics regression analyses were performed to determine the independent risk factors for mortality, poor hip function or poor ability to perform ADL. The mortality rate was 15.6% (75/480). In the survivors, poor outcome developed in 133 (32.8%) patients and poor ADL was in 72 (17.8%) patients. The independent factors that influenced mortality were advanced age (p = 0.033), male gender (0.031), living in rural area (p < 0.001), self-reported diabetes (p = 0.005), tumor (p = 0.024), preoperative delay >7 days (p = 0.020), postoperative drainage use (p = 0.034), WBC > 10 × 10⁹/L (p = 0.005), reduced RBC (p = 0.011), PLT < 100 × 10⁹/L (p < 0.001), ALB < 35 g/L (p < 0.001) and CK > 200 U/L (p = 0.003). The independent factors that influenced the hip function were male gender (p = 0.009), WBC > 10 × 10⁹/L (p < 0.001), lower HBG (p = 0.005), and ALB < 35 g/L (p < 0.001). The independent factors that influenced the ability to perform ADL were diagnosis of trochanteric fracture (p = 0.048), preoperative delay > 7 days (p = 0.027), postoperative drainage use (p = 0.010), elevated WBC (p = 0.020), lower HGB (p < 0.001), PLT < 100 × 10⁹/L (p = 0.002), and ALB < 35 g/L (p < 0.001). Although most of risk factors were not modifiable, they aid in patient individual risk evaluation, risk stratification, and counseling patients or relatives.

The epidemiology of osteoporosis, associated fragility fractures, and management gap in China

BACKGROUND

Osteoporosis has been one of the most common but largely under-diagnosed clinical problems among elderly population. The disease burden is even greater in China because of limited medical resources and large population size. This article is aimed to provide an overview of disease burden, secular trend, and management gap of osteoporosis and related fractures in China.

METHODS

Based on the related studies published in English and Chinese from 1990 to 2017, we investigated the prevalence/incidence of osteoporosis and osteoporotic fracture in Chinese mainland, Hong Kong, and Taiwan, characterizing the secular trend and disease burden in different regions. Strict inclusion criteria were applied to control the study quality. We further examined the diagnosis and treatment gap of osteoporosis management observed in clinical practice in China and summarized the efforts made by Chinese government and scholars to combat this situation.

RESULTS

Twenty-seven studies concerning osteoporosis prevalence in China (including Chinese mainland, Hong Kong, and Taiwan) met the inclusion criteria and were included in the final analysis. Another 15 studies about hip fracture incidence and 13 studies about vertebral fracture prevalence/incidence were also included. The epidemiological data varied greatly across studies due to different design and population included. A higher prevalence was indicated in female population, older age groups, and residents in northern China compared to their counterparts. Though attenuated increased rates or slight decline patterns have been observed in Hong Kong and Taiwan, osteoporotic fracture incidence still showed steady increase in Chinese mainland. The diagnosis and treatment of osteoporosis as well as post-fracture management were still insufficient in China.

CONCLUSION

Due to its silent nature, osteoporosis and its related fractures remain largely under-diagnosed and under-managed in China. It also highlights the scarcity of high-quality studies specifically focus on longtime documentation of disease burden change and male population, especially in mainland area.

Oral bisphosphonate prescription and non-adherence at 12 months in patients with hip fractures treated in an acute geriatric unit

A poorer functional status at the time of fracture is a predictor of non-adherence to oral bisphosphonates initiated after a hip fracture, and suggests further opportunities for optimization of secondary fracture prevention in this high-risk population.

INTRODUCTION

Low adherence to treatment is a problem in post-fracture secondary prevention. We aimed to analyze the prognostic factors (related and predictive) associated with non-adherence to oral bisphosphonate prescription for hip fracture due to bone fragility (HFBF) 12 months after discharge from an acute geriatric unit.

METHODS

Prospective study of bivariate data analyzing related and multivariate factors predicting non-adherence of oral bisphosphonates at 12 months after treatment for HFBF. The statistical study was performed with SPSS 19.0.0.

RESULTS

We attended 368 patients with HFBF. At discharge, oral bisphosphonates were prescribed to 226 (61.42%) patients. At 12 months, we followed up 160 (70.7%) patients, 104 (65%) of whom had non-adherence to oral bisphosphonates. Bivariate analysis (adherent vs. non-adherent): age (83.79 ± 5.82 vs. 85.78 ± 5.80, p = .029); Lawton and Brody Index (4.29 ± 3.40 vs. 2.67 ± 3.31, p = .004); baseline Barthel Index (BI) (85.89 ± 21.99 vs. 74.18 ± 26.70) (p = .004); BI at admission (18.84 ± 10.00 vs. 14.47 ± 11.71, p = .004); BI at discharge (34.20 ± 15.40 vs. 27.45 ± 16.71, p = .011); baseline Functional Ambulation Classification (5.66 ± 0.98 vs. 5.43 ± 0.99, p = .025). Multivariate analysis: BI 0.980 (0.965-0.995, p = .007). Discriminatory capacity of the AUC model (± 95% CI): 0.634 (0.545-0.722).

CONCLUSIONS

At 12 months, there was low adherence to treatment with oral bisphosphonates in our model. A lower BI prior to treatment is a predictive factor for non-adherence treatment with oral bisphosphonate.