Real-world Adherence and Persistence with Bisphosphonate Therapy in Postmenopausal Women: A Systematic Review

Feasibility and effectiveness of a digital voice assistant for improving anti-osteoporosis medication adherence, and osteoporosis knowledge and attitudes, in postmenopausal women with osteoporosis: A 12-month randomised controlled trial

Digital voice assistants (DVAs) are feasible for delivering a digital health intervention designed to improve osteoporosis self-management in postmenopausal women with osteoporosis. However, the DVA intervention did not improve anti-osteoporosis drug adherence, nor did it enhance osteoporosis knowledge or attitudes in this population.

PURPOSE

To determine feasibility and effectiveness of a digital voice assistant (DVA) intervention for improving anti-osteoporosis medication adherence, and osteoporosis knowledge and attitudes, in postmenopausal women with osteoporosis.

METHODS

This 12-month single-blinded, randomised controlled trial included 50 postmenopausal women with osteoporosis randomised to DVA (N = 25) or control (N = 25) for 6 months, followed by a 6-month follow-up period. DVA participants received an Amazon Alexa device that delivered osteoporosis education videos, medication reminders and interactive quizzes. Control participants received emails with links to osteoporosis information. Anti-osteoporosis medication possession ratio (MPR; acceptable adherence defined as ≥ 0.8) was determined using Pharmaceutical Benefits Schedule data. Osteoporosis knowledge was measured using the Osteoporosis Knowledge Assessment Tool (OKAT) and medication attitudes were measured using the Adherence Evaluation of Osteoporosis Treatment (ADEOS-12) questionnaire.

RESULTS

The mean ± SD age of participants was 64.3 ± 6.1 years and 6-month DVA intervention adherence (number of DVA sessions accessed) was 79.5% (95%CI: 73.9, 84.9). The proportion of participants with acceptable 12-month MPRs was similar between groups (control: 86.4% [95%CI: 77.0, 93.6]; DVA: 95.0% [95%CI: 88.4, 100.0], P = 0.34). Mean OKAT scores improved in both groups after both 6- and 12 months, but there were no significance between groups. Changes in mean ADEOS-12 scores did not differ between baseline and 6 months in DVA compared to control (0.61 [95%CI: - 0.80, 2.03]) but worsened post-intervention from 6 to 12 months (net difference: - 1.42 [95%CI: - 2.80, - 0.06]).

CONCLUSIONS

This DVA-delivered intervention achieved good adherence but did not improve medication adherence, osteoporosis knowledge, or attitudes compared with control. Future studies should target populations with poor adherence to anti-osteoporosis medication.

Long-term adherence to anti-osteoporosis medication and determinants of adherence in the population-based screening trial ROSE

Screening initiatives for osteoporosis must facilitate treatment of those at elevated fracture risk. In a randomized controlled trial of 24,229 women, those in the screening group with FRAX ≥ 15% were invited for DXA with AOM treatment offered as per national guidelines. Treatment initiation in the following year was 9.5 times higher compared with controls.

PURPOSE

To determine if screened individuals have lower adherence to anti-osteoporotic medication (AOM) than unscreened and to examine determinants for low treatment adherence.

METHOD

In 2010/2011, women aged 65-80 (N = 34,229) in the Region of Southern Denmark were invited to the risk-stratified osteoporosis strategy evaluation (ROSE) randomized study. Women in the screening group with moderate to high 10-year fracture risk (FRAX® ≥ 15%) were invited for dual-energy x-ray absorptiometry with AOM treatment as per national guidelines. Screened, controls, and an age-matched general population sample were compared for adherence to AOM using 10-year follow-up data on prescription and hospital records.

RESULTS

Among ROSE participants with FRAX ≥ 15%, 5864 screened and 5790 controls were eligible for analysis, along with an equal number from the general population. AOM initiation in the first year was 9.5 times higher in screened compared to controls (HR 9.50, 7.16; 12.61). There was no difference in implementation assessed as medication possession ratio. The 5-year persistence rates were similar in screened and controls (51-52%), but lower in the general population (44%). FRAX risk factors partly influenced AOM initiation in the screened, with different patterns in other groups. Immobilization, comorbidities, and co-medications were key determinants of discontinuation in both the short and long term.

CONCLUSION

The ROSE screening programme significantly increased treatment initiation in postmenopausal women. Screened women showed similar treatment adherence levels to non-screened once they started medication. However, frail women were more prone to treatment discontinuation, highlighting the need for targeted support in this subgroup.

TRIAL REGISTRATION

The original ROSE trial is registered at ClinicalTrials.gov (NCT01388244). The study protocol has been published in Rubin et al. The risk-stratified osteoporosis strategy evaluation study (ROSE): a randomized prospective population-based study. Design and baseline characteristics. Calcif Tissue Int. 2015;96(2):167-79.

Real world clinical outcomes when discontinuing denosumab or bisphosphonates in patients with surgically managed osteoporotic vertebral compression fractures: a population-based cohort study

BACKGROUND CONTEXT

Osteoporotic vertebral compression fractures (OVCFs) are common fragility fractures. Patients who undergo surgical treatment for their initial OVCFs warrant particular attention because there is an elevated risk of subsequent vertebral fractures and other types of fragility fractures. However, the optimal osteoporosis treatment for this specific patient group is less investigated.

PURPOSE

This study compares the risk of subsequent osteoporotic fractures and mortality rate for patients who are initiated with denosumab and bisphosphonates and determines the effect of adherence to treatment.

STUDY DESIGN

Retrospective nationwide cohort study PATIENT SAMPLE: A total of 2,858 patients who had surgically-managed osteoporotic vertebral compression fractures.

OUTCOME MEASURES

The risk of osteoporotic fractures, vertebral fractures, nonvertebral fractures and death.

METHODS

This is a retrospective nationwide cohort study that uses the National Health Insurance Research Database. Patients aged ≥50 years who were admitted for surgical interventions for OVCF between 2012 and 2016 and subsequently received denosumab or bisphosphonates for one year were included. Patients were stratified according to their antiosteoporosis medications and adherence to treatment. A multivariable, time-varying Cox proportional hazards model was used to determine the risk of osteoporotic fractures, vertebral fractures, nonvertebral fractures and death.

RESULTS

A total of 2,858 patients were included in this study: 1,123 patients in the denosumab group and 1,735 patients in the bisphosphonates group. Compared to persistent denosumab users, the nonpersistent denosumab users, persistent bisphosphonate users and nonpersistent bisphosphonate users had a greater risk of osteoporotic fractures, with respective hazard ratios of 1.64 (95% confidence interval [CI], 1.16-2.32), 1.74 (95% CI, 1.25-2.42) and 1.53 (95% CI, 1.14-2.06). If osteoporotic fractures were divided into nonvertebral and vertebral fractures, none of the groups exhibited an increased risk of vertebral fractures compared to persistent denosumab users, with an HR of 1.00 (95% CI: 0.54-1.88) for nonpersistent denosumab users, 1.64 (95% CI: 0.96-2.81) for persistent bisphosphonate users and 1.52 (95% CI: 0.95-2.43) for nonpersistent bisphosphonate users. However, there was a significantly greater risk of nonvertebral fracture, with respective hazard ratios of 2.04 (95% CI, 1.33-3.11), 1.80 (95% CI, 1.18-2.76) and 1.56 (95% CI, 1.06-2.27) for nonpersistent denosumab users, persistent bisphosphonate users and nonpersistent users. Noteworthy, nonpersistent denosumab users exhibited a significantly greater risk of mortality than persistent denosumab users, with a hazard ratio of 3.12 (95% CI, 2.22-4.38).

CONCLUSIONS

In terms of patients with OVCFs who require hospitalization and surgical intervention, those who receive ongoing denosumab treatment exhibit less risk of developing subsequent osteoporotic fractures than those who receive bisphosphonates or nonpersistent denosumab treatment. However, discontinuation of denosumab is associated with a significantly increased risk of subsequent fractures and mortality. Therefore, adherence to the treatment is crucial for patients who are initiated with denosumab.

Fructooligosaccharides act on the gut-bone axis to improve bone independent of Tregs and alter osteocytes in young adult C57BL/6 female mice

Targeting the gut-bone axis with probiotics and prebiotics is considered as a promising strategy to reduce the risk of osteoporosis. Gut-derived short chain fatty acids (SCFA) mediate the effects of probiotics on bone via Tregs, but it is not known whether prebiotics act through a similar mechanism. We investigated how 2 different prebiotics, tart cherry (TC) and fructooligosaccharide (FOS), affect bone, and whether Tregs are required for this response. Eight-wk-old C57BL/6 female mice were fed with diets supplemented with 10% w/w TC, FOS, or a control diet (Con; AIN-93M) diet, and they received an isotype control or CD25 Ab to suppress Tregs. The FOS diet increased BMC, density, and trabecular bone volume in the vertebra (~40%) and proximal tibia (~30%) compared to the TC and control diets (Con), irrespective of CD25 treatment. Both prebiotics increased (P < .01) fecal SCFAs, but the response was greater with FOS. To determine how FOS affected bone cells, we examined genes involved in osteoblast and osteoclast differentiation and activity as well as genes expressed by osteocytes. The FOS increased the expression of regulators of osteoblast differentiation (bone morphogenetic protein 2 [Bmp2], Wnt family member 10b [Wnt10b] and Osterix [Osx]) and type 1 collagen). Osteoclasts regulators were unaltered. The FOS also increased the expression of genes associated with osteocytes, including (Phex), matrix extracellular phosphoglycoprotein (Mepe), and dentin matrix acidic phosphoprotein 1 (Dmp-1). However, Sost, the gene that encodes for sclerostin was also increased by FOS as the number and density of osteocytes increased. These findings demonstrate that FOS has a greater effect on the bone mass and structure in young adult female mice than TC and that its influence on osteoblasts and osteocytes is not dependent on Tregs.

Global burden of hip fracture: The Global Burden of Disease Study

This study is the first to measure global burden of hip fracture in patients aged 55 years and older across 204 countries and territories from 1990 to 2019. Our study further proved that the global burden of hip fracture is still large. Hip fractures among males are perhaps underestimated, and older adults should be given more attention.

PURPOSE

Hip fracture is a tremendous universal public health challenge, but no updated comprehensive and comparable assessment of hip fracture incidence and burden exists for most of the world in older adults.

METHODS

Using data from the Global Burden of Diseases (GBD) 2019, we estimated the number and rates of the incidence, prevalence, and years lived with disability (YLD) of hip fracture across 204 countries and territories in patients aged 55 years and older from 1990 to 2019.

RESULTS

In 2019, the incidence, prevalence, and YLDs rates of hip fracture in patients aged 55 years and older were 681.35 (95% UI 508.36-892.27) per 100000 population, 1191.39 (95% UI 1083.80-1301.52) per 100000 population, and 130.78 (95% UI 92.26-175.30) per 100000 population. During the three decades, the incidence among people aged below 60 years showed a downward trend, whereas it showed a rapid upward trend among older adults. All the numbers and rates of hip fractures among females were higher than those among males and increased with age, with the highest number and rate in the highest age group. Notably, the male to female ratio of the incidence for people aged over 55 years increased from 0.577 in 1990 to 0.612 in 2019. Falls were the leading cause among both sexes and in all age groups.

CONCLUSIONS

The incidence and the number of hip fractures among patients aged 55 years and older increased over the past three decades, indicating that the global burden of hip fracture is still large. Hip fractures among males are perhaps underestimated, and older adults should be given more attention.

Treatment Persistence and Medication Switch Associated With Subsequent Fractures After Osteoporotic Fractures

CONTEXT

Despite prevalent anti-osteoporosis medication (AOM) switching in real-world osteoporosis management, few studies have evaluated the impact of persistent AOM treatment, allowing for AOM switching, on the risk of subsequent fracture.

OBJECTIVE

We examined the association between persistence in AOM and subsequent fractures, allowing for medication switching among patients with osteoporotic fractures.

METHODS

This retrospective cohort study used Taiwan National Health Insurance claims data to select patients who initiated AOM between 2013 and 2016. Treatment persistence was defined as use of any AOM on a given day of interest with a 45-day grace period. Medication switch was allowed for persistence if remaining on treatment. AOMs with long-lasting inhibition of bone resorption (zoledronate and denosumab) were categorized as high-potency; others as low-potency. Multivariate Cox models were used to evaluate risk of subsequent fractures ≥3 months after initiating AOM.

RESULTS

A total of 119 473 patients were included (mean [SD] follow-up 46.4 [15.6] months), and 26.8% switched from the index AOM. Within 1 year, 52% remained persistent with AOM. Compared to patients with persistent AOM, those not persistent had higher risk of subsequent hip (adjusted hazard ratio [aHR] = 1.31; 95% CI, 1.21-1.42), vertebral (aHR = 1.17; 95% CI, 1.13-1.22), and radius fractures (aHR = 1.16; 95% CI, 1.08-1.25). Patients with persistent AOM who switched from high- to low-potency AOM had higher risk of subsequent vertebral fractures than those with persistent AOM and no potency switch (aHR = 1.28; 95% CI, 1.02-1.60).

CONCLUSION

Patients with non-persistent AOM had higher risk of subsequent fractures than persistent users when allowing AOM switch. Switching AOM potency may influence the risk of subsequent vertebral fractures and warrants further investigation.

Adherence of denosumab treatment for low bone mineral density in Japanese people living with HIV: a retrospective observational study

BACKGROUND

Long-term care issues, specifically metabolic bone disorders, are a concern for people living with human immunodeficiency virus (PLWH) who undergo life-long antiretroviral therapy (ART). Previous clinical trials with denosumab, an anti-RANKL antibody inhibitor, have revealed its effectiveness in increasing bone mineral density (BMD) in patients with osteoporosis. However, there are limited data on adherence and effectiveness of denosumab treatment for osteoporosis in PLWH. Hence, this study aimed to investigate the adherence and effectiveness of denosumab treatment for osteoporosis in Japanese PLWH.

METHODS

This study is a retrospective exploratory analysis of 29 Japanese PLWH who initiated denosumab treatment for osteoporosis, between 2013 and 2021. The study included patients who received at least one dose of denosumab every 6 months. Adherence and persistence were defined as receiving two consecutive injections of denosumab 6 months ± 4 weeks apart and 6 months + 8 weeks apart, respectively. The primary outcome measure of the study was the adherence of denosumab treatment for 24 months. The secondary outcome measures included treatment persistence and BMD. The period after January 2020 was defined as the coronavirus disease 2019 (COVID-19) pandemic period, and its impact on adherence was investigated.

RESULTS

The treatment adherence rates at 12 and 24 months were 89.7% and 60.7%, respectively. By contrast, the treatment persistence at 12 and 24 months was 100% and 85.7%, respectively. More patients in the group who initiated denosumab treatment after the COVID-19 pandemic reached non-adherence than in the group who initiated denosumab treatment before the pandemic. BMD at the lumbar spine and femoral neck significantly increased compared to that at baseline, with median percentage changes of 8.7% (p < 0.001) and 3.5% (p = 0.001), respectively.

CONCLUSIONS

The results showed that patients in the study had a high rate of non-adherence but a lower rate of non-persistence. Additionally, PLWH on ongoing ART experienced increased BMD with denosumab treatment. This study provides an opportunity to improve future strategies for denosumab treatment in the Japanese PLWH.

Using sequential pharmacotherapy for the treatment of osteoporosis: an update of the literature

INTRODUCTION

Osteoporosis, which is characterized by compromised bone density and heightened susceptibility to fractures, is a substantial public health concern, especially among the aging population. Underdiagnosis, undertreatment, and therapy non-adherence contribute to its impact. Anabolic and dual-action agents like teriparatide, abaloparatide, and romosozumab have emerged as effective treatments, allowing rapid gains in bone mineral density (BMD) and reducing fracture risk. However, administering treatments in the correct order is paramount, with an 'anabolic first' approach gaining traction for patients at high risk of fractures. This strategy involves starting anabolic therapies, followed by antiresorptive agents as maintenance therapy. It is important to note that the effectiveness of anabolic agents differs between treatment-naive and previously treated patients: tailored treatment approaches are therefore necessary. This comprehensive strategy adheres to clinical guidelines, emphasizing individualized care, early intervention, and patient-centered management to mitigate the burden of osteoporosis and enhance patients' quality of life.

AREA COVERED

The aim of this review is to summarize recent evidence on the sequential treatment of osteoporosis and to provide recommendations on the best treatment strategies.

EXPERT OPINION

Effective treatments, such as anabolic agents, are key in high-risk patients, who require an 'anabolic first' approach. Sequential therapy, specifically tailored to a patient's history, can help to optimize prevention and management of fractures.

Adjuvant denosumab in early breast cancer: a systematic review and meta-analysis of randomized controlled clinical trials

Background

In early breast cancer (BC) the impact of denosumab on survival outcomes is still unclear. We undertook a systematic review and meta-analysis to assess efficacy and safety of adjuvant denosumab in addition to standard anticancer therapy.

Methods

PubMed, CENTRAL, Scopus, Embase, and oncological meetings websites were screened to identify potentially eligible randomized controlled trials (RCTs). Survival outcomes were disease-free survival (DFS), bone-metastasis-free survival (BMFS), and overall survival (OS). Fracture incidence and time to first fracture were bone-health outcomes. Osteonecrosis of the jaw (ONJ), atypical femur fractures (AFF), and other adverse events were also evaluated. Pooled hazard ratios (HRs) and risk ratios (RR) with respective 95% confidence interval (95% CI) were computed using a random-effects model. Exploratory subgroup analyses were performed.

Results

Two phase III RCTs were included, the Austrian Breast & Colorectal Cancer Study Group-18 (ABCSG-18) and the D-CARE trials, for a total of 7929 patients. In the ABCSG-18 trial, denosumab was administered every 6 months during endocrine therapy (for a median of seven cycles) while the D-CARE trial used an intensive schedule for a total treatment duration of 5 years. Adjuvant denosumab showed no difference in DFS (HR: 0.932; 95% CI: 0.748-1.162), BMFS (HR: 0.9896; 95% CI: 0.751-1.070), and OS (HR: 0.917; 95% CI: 0.718-1.171) compared to placebo in the overall population. In hormone receptor positive/human epidermal growth factor receptor 2 (HER2) negative BC patients, a DFS (HR: 0.883; 95% CI: 0.782-0.996) and BMFS (HR: 0.832; 95% CI: 0.714-0.970) benefit was observed and BMFS was prolonged in all hormone receptor positive patients (HR: 0.850; 95% CI: 0.735-0.983). Fracture incidence (RR: 0.787; 95% CI: 0.696-0.890) and time to first fracture (HR: 0.760; 95% CI: 0.665-0.869) were also improved. No increase in overall toxicity was seen with denosumab and no differences were observed for ONJ and AFF between the 60-mg every 6-month schedule and placebo.

Conclusion

Denosumab addition to anticancer treatment does not improve DFS, BMFS, or OS in the overall population, although a DFS improvement was observed in hormone receptor positive/HER2 negative BC patients and a BMFS improvement in all hormone receptor positive patients. Bone-health outcomes were improved with no added toxicity with the 60-mg schedule.

Registration

PROSPERO identifier: CRD42022332787.

Fracture risk in women with osteoporosis initiated on gastro-resistant risedronate versus immediate release risedronate or alendronate: a claims data analysis in the USA

The study results indicate that women with osteoporosis initiated on gastro-resistant risedronate have a lower risk of fracture than those initiated on immediate release risedronate or alendronate. A large proportion of women discontinued all oral bisphosphonate therapies within 1 year of treatment start.

PURPOSE

Using a US claims database (2009-2019), we compared risk of fractures between women with osteoporosis initiated on gastro-resistant (GR) risedronate and those initiated on (a) immediate release (IR) risedronate or (b) immediate release alendronate.

METHODS

Women aged ≥ 60 years with osteoporosis who had ≥ 2 oral bisphosphonate prescription fills were followed for ≥ 1 year after the first observed bisphosphonates dispensing (index date). Fracture risk was compared between the GR risedronate and IR risedronate/alendronate cohorts using adjusted incidence rate ratios (aIRRs), both overall and in subgroups with high fracture risk due to older age or comorbidity/medications. Site-specific fractures were identified based on diagnosis codes recorded on medical claims using a claims-based algorithm. Persistence on bisphosphonate therapy was evaluated for all groups.

RESULTS

aIRRs generally indicated lower fracture risk for GR risedronate than IR risedronate and alendronate. When comparing GR risedronate to IR risedronate, statistically significant aIRRs (p < 0.05) were observed for pelvic fractures in the full cohorts (aIRRs = 0.37), for any fracture and pelvic fractures among women aged ≥ 65 years (aIRRs = 0.63 and 0.41), for any fracture and pelvic fractures among women aged ≥ 70 years (aIRRs = 0.69 and 0.24), and for pelvic fracture among high-risk women due to comorbidity/medications (aIRR = 0.34). When comparing GR risedronate to alendronate, statistically significant aIRRs were observed for pelvic fractures in the full cohorts (aIRR = 0.54), for any fracture and wrist/arm fractures among women aged ≥ 65 years (aIRRs = 0.73 and 0.63), and for any fracture, pelvic, and wrist/arm fractures among women aged ≥ 70 years (aIRRs = 0.72, 0.36, and 0.58). In all cohorts, ~ 40% completely discontinued oral bisphosphonates within 1 year.

CONCLUSIONS

Discontinuation rates of oral bisphosphonate therapy were high. However, women initiated on GR risedronate had a significantly lower risk of fracture for several skeletal sites than women initiated on IR risedronate/alendronate, particularly those aged ≥ 70 years.

Novel formulations of oral bisphosphonates in the treatment of osteoporosis

Oral bisphosphonates are a key intervention in the treatment of osteoporosis and in reducing the risk of fragility fractures. Their use is supported by over 3 decades of evidence; however, patient adherence to oral bisphosphonates remains poor in part due to complex dosing instructions and adverse events, including upper gastrointestinal symptoms. This problem has led to the development of novel oral bisphosphonate formulations. Buffered, effervescent alendronate is dissolved in water and so seeks to reduce upper gastro-intestinal adverse events, and gastro-resistant risedronate aims to reduce the complexity of dosing procedure (e.g. fasting prior to consumption) whilst still maintaining the efficacy of fracture risk reduction. Clinical trials and real-world data have been employed to demonstrate some benefits in terms of reduced upper gastro-intestinal adverse events, adherence, persistence and health economic outcomes. This report describes the result of an ESCEO (European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis) expert working group, which explores where oral bisphosphonates sit in current clinical practice guidelines, review their risk-benefit profile and the consequences of poor adherence before exploring novel oral bisphosphonate formulations and their potential clinical and health economic impact. Further research is required but there are signs that these novel, oral bisphosphonate formulations may lead to improved tolerance of oral bisphosphonates and thus, improved adherence and fracture outcomes.

Adherence of bisphosphonate and decreased risk of clinical vertebral fracture in osteoporotic patients: A propensity score matching analysis

Objectives

Bisphosphonate is associated with a decreased risk of vertebral fractures due to osteoporosis. However, there are limited studies on how poor compliance with bisphosphonate affects the risk of vertebral fractures in a nationwide cohort. We aim to evaluate whether adherence to bisphosphonate affects the risk of fracture in osteoporosis patients.

Methods

We used the data of the Korean National Health Insurance Service Senior Cohort. A total of 33,315 (medication possession ratio [MPR]: 50) osteoporosis patients were matched using the propensity score matching method: those who received low-dose bisphosphonate and those who received high-dose bisphosphonate. Twenty-two confounding variables, including age, socioeconomic status, medications prescribed, and underlying diseases that may affect the risk of fracture were adjusted for propensity score matching. The risk of vertebral fracture was assessed by Cox proportional hazards regression.

Results

Patients with a higher MPR showed a decreased vertebral fracture risk than those with a lower MPR (MPR 50 = hazard ratio [HR] 0.909; 95% confidence interval [CI] 0.877–0.942 P < 0.001; MPR 70 = HR: 0.874, 95% CI: 0.838–0.913, P < 0.001; MPR 90 = HR: 0.822, 95% CI: 0.780–0.866, P < 0.001). MPR was associated with a decreased vertebral fracture risk in both groups with or without history of fracture. In the subgroup analysis, MPR was associated with a decreased vertebral fracture risk in women, in all ages, with or without T2DM, and with or without hypertension.

Conclusions

Higher MPR is associated with a lower vertebral fracture risk.

Osteoporotic Fractures among Selective Estrogen Receptor Modulator Users in South Korea: Analysis Using National Claims Database

Background

We evaluated (1) compliance with selective estrogen receptor modulator (SERM) use in postmenopausal women; and (2) the risk of osteoporotic fractures according to compliance and other patient characteristics.

Methods

National claims data of postmenopausal women from January 2013 to December 2014 were reviewed. Demographics, comorbidities, type of medical institution, and patient compliance were investigated. Compliance was measured according to medication possession ratio (MPR) and the patients were classified into compliant (MPR ≥80%) or non-compliant (MPR <80%) groups. Osteoporotic fractures were followed up for 2 years after prescription.

Results

Among 15,166 postmenopausal women, 4,130 were categorized as compliant. Osteoporotic fractures were confirmed in 669 patients. The hip fracture rate in the non-compliant group (0.39%) was marginally higher than that in the compliant group (0.36%; P=0.06). Compared to age 50 to 54 years, age 55 to 59 years showed protection against fractures (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.379–0.857; P=0.007), while those over 70 years showed a higher risk of fractures (HR, 2.035; 95% CI, 1.485–2.789; P<0.0001 for age 70–74 years; HR, 2.197; 94% CI, 1.588–3.041; P<0.0001 for age 75–79 years; and HR, 3.53; 95% CI, 2.493–4.999; P<0.0001 for age ≥80 years). Patients with mild (HR, 1.29; 95% CI, 1.088–1.530; P=0.0034) and moderate (HR, 1.286; 95% CI, 1.002–1.652; P=0.0486) comorbidities were associated with higher risks of fractures compared to those without comorbidities.

Conclusions

Among postmenopausal women with osteoporosis, only 27.2% complied with SERM therapy. A marginal difference in hip fracture rate was observed between the compliant and non-compliant groups. Older age and severe comorbidities were associated with higher risks of osteoporotic fractures.

Osteoporosis in men

Osteoporosis in men is a common but often overlooked disorder by clinicians. The criterion for osteoporosis diagnosis in men is similar to that in women-namely, a bone mineral density (BMD) that is 2·5 standard deviations or more below the mean for the young adult population (aged 20-29 years; T-score -2·5 or lower), measured at the hip or lumbar spine. Sex steroids are important for bone health in men and, as in women, oestrogens have a key role. Most men generally have bigger and stronger bones than women and typically have less bone loss during their lifetime. Men typically fracture less often than women, although they have a higher mortality rate after a fracture. Secondary osteoporosis is more common in men than in women. Lifestyle changes, adequate calcium, vitamin D intake, and exercise programmes are recommended for the management of osteoporosis in men. Bisphosphonates, denosumab, and teriparatide have been shown to increase BMD and are used for pharmacological treatment. In this Review, we report an updated overview of osteoporosis in men, describe new treatments and concepts, and discuss persistent controversies in the area.

Real-World Effectiveness of Anti-Resorptive Treatment in Patients With Incident Fragility Fractures-The STORM Cohort-A Swedish Retrospective Observational Study

Results from real-world evidence (RWE) from the largest healthcare region in Sweden show low uptake of antiresorptive (AR) treatment, but beneficial effect in those receiving treatment, especially for the composite outcome of hip fracture or death. For RWE studies, Sweden is unique, with virtually complete coverage of electronic medical records (EMRs) and both regional and national registries, in a universal publicly funded healthcare system. To our knowledge, there is no previous RWE study evaluating the efficacy of AR treatment compared to no AR treatment after fragility fracture, including data on parenteral treatments administered in hospital settings. The Stockholm Real World Management (STORM) study cohort was established in the healthcare region of Stockholm to retrospectively assess the effectiveness of AR treatment after first fragility fracture using the regional EMR system for both hospital and primary care. Between 2012 and 2018, we identified 69,577 fragility fracture episodes among 59,078 patients, men and women, 50 years and older. Of those, 21,141 patients met inclusion and exclusion criteria (eligible cohort). From these, the final matched study cohort comprised 9840 fragility fractures (cases receiving AR treatment [n = 1640] and controls not receiving AR treatment [n = 8200]). Propensity scores were estimated using logistic regression models with AR treatment as outcome and confounders as independent variables followed by analysis using Cox proportional hazard models. Real world evidence from Sweden's largest healthcare region, comprising a quarter of the Swedish population, show that only 10% of patients receive AR treatment within 1 year after a fragility fracture. Factors associated with not receiving treatment include having a diagnosis of cardiovascular disease. In those treated, AR have positive effects particularly on the composite of fracture and death (any fracture/death and hip fracture/death) in individuals matched for all major confounders. © 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).

Management of Postmenopausal Osteoporosis: ACOG Clinical Practice Guideline No. 2

PURPOSE

To provide updated evidence-based recommendations for the treatment of postmenopausal osteoporosis.

TARGET POPULATION

Postmenopausal patients with primary osteoporosis.

METHODS

This guideline was developed using an a priori protocol in conjunction with a writing team consisting of two specialists in obstetrics and gynecology appointed by the ACOG Committee on Clinical Practice Guidelines-Gynecology and one external subject matter expert. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS

This Clinical Practice Guideline includes updated recommendations on who should receive osteoporosis pharmacotherapy, the benefits and risks of available pharmacotherapy options, treatment monitoring and follow-up, and the role of calcium and vitamin D in the management of postmenopausal osteoporosis. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

Nitrogen-Based Bisphosphonate Use and Ovarian Cancer Risk in Women Aged 50 Years and Older

BACKGROUND

There are few readily modifiable risk factors for epithelial ovarian cancer; pre-clinical studies suggest bisphosphonates could have chemo-preventive actions. Our study aimed to assess the association between use of nitrogen-based bisphosphonate medicine and risk of epithelial ovarian cancer, overall and by histotype.

METHODS

We conducted a case-control study nested within a large linked administrative dataset including all Australian women enrolled for Medicare, Australia's universal health insurance scheme, between July 2002 and December 2013. We included all women with epithelial ovarian cancer diagnosed at age 50 years and older between 1st July 2004 and 31st December 2013 (n = 9,367) and randomly selected up to five controls per case, individually matched to cases by age, state of residence, area-level socioeconomic status, and remoteness of residence category (n = 46,830). We used prescription records to ascertain use of nitrogen-based bisphosphonates (ever use and duration of use), raloxifene and other osteoporosis medicines (non-nitrogen-based bisphosphonates, strontium and denosumab). We calculated adjusted odds ratios (OR) and 95% confidence intervals (CI) using conditional logistic regression.

RESULTS

Ever use of nitrogen-based bisphosphonates was associated with a reduced risk of epithelial ovarian cancer compared to non-use (OR = 0.81, 95%CI : 0.75-0.88). There was a reduced risk of both endometrioid (OR = 0.51, 95%CI : 0.33-0.79) and serous histotypes (OR = 0.84, 95%CI : 0.75-0.93), but no association with the mucinous or clear cell histotypes.

CONCLUSION

Use of nitrogen-based bisphosphonates was associated with a reduced risk of endometrioid and serous ovarian cancer. This suggests the potential for use for prevention, although validation of our findings is required.

Prevalence, Incidence Rate, and Risk Factors of Medication-Related Osteonecrosis of the Jaw in Patients With Osteoporosis and Cancer: A Nationwide Population-Based Study in Japan

PURPOSE

Medication-related osteonecrosis of the jaw (MRONJ) is a rare but severe adverse event of antiresorptive agents. However, the precise prevalence and factors associated with the development of MRONJ remain unknown. The present study was performed to describe the prevalence, incidence rate, and risk factors of developing MRONJ.

METHODS

We conducted a population-based retrospective cohort study using the National Database of Health Insurance, an administrative claims database of all patients in Japan. We identified patients who newly began using antiresorptive drugs from April 2015 to December 2018. The primary outcome was the development of MRONJ. We calculated the prevalence and incidence rate of MRONJ and performed a time-dependent Cox proportional hazard regression analysis to examine risk factors for developing MRONJ.

RESULTS

We identified 2,819,310 patients who newly used antiresorptive drugs during the study period. Of these patients, 2,664,104 (94.5%) had osteoporosis and 155,206 had cancer. Among the patients with osteoporosis, 1,603 (0.06%) developed MRONJ; the incidence rate was 22.9 per 100,000 person-years. Among the patients with cancer, 2,274 (1.47%) developed MRONJ; the incidence rate was 1,231.7 per 100,000 person-years. The occurrence of MRONJ was associated with poor oral conditions (including tooth extraction), age, male sex, drug type, concomitant drug use, comorbidities, cancer type, and geographic location.

CONCLUSIONS

The overall prevalence and incidence rate were low, but they were still higher than those in previous studies. Poor oral conditions were more closely related to the development of MRONJ than other factors. These findings suggest that improving poor oral hygiene may be essential to prevent MRONJ.

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.

Over half of seniors who start oral bisphosphonate therapy are exposed for 3 or more years: novel rolling window approach and patterns of use

Most adherence studies only consider treatment following a first prescription. Using an extended follow-up, we found that 60% of seniors starting oral bisphosphonate therapy were exposed for ≥ 3 years (48% for ≥ 5 years). Studies are needed to examine the benefits and harms of continuing bisphosphonate therapy beyond 3 years.

INTRODUCTION

The purpose of this study was to identify and describe patterns of long-term oral bisphosphonate use among seniors using a novel methodological approach that considers extended follow-up.

METHODS

Among Ontarians aged 66 years or older, we identified subjects with a first dispensing of alendronate or risedronate between November 2000 and December 2016. We followed them until death or December 2019 to identify patients with ≥ 3 years of bisphosphonate use, defined as a proportion of days covered ≥ 80%, using 3-year rolling windows. We calculated the proportion of patients with long-term therapy (≥ 3 years of use) using Kaplan-Meier estimates. We described patterns of long-term use and compared patient characteristics between patients with and without long-term therapy.

RESULTS

We identified 260,784 eligible seniors initiating bisphosphonate therapy. Of these, 60% continued therapy ≥ 3 years (77% women), and 48% continued ≥ 5 years. Characteristics did not meaningfully differ between patients with or without long-term therapy. The median length of long-term therapy was 7.0 (IQR 5.1) years for women and 6.1 (IQR 4.3) years for men. Only 20% experienced a treatment gap before long-term therapy, yet 50% experienced a treatment gap of ≥ 120 days after a median 5.3 years of therapy. Eighty-one percent who returned to therapy following a treatment gap re-initiated an oral bisphosphonate, with 18% switching to denosumab.

CONCLUSIONS

Among seniors initiating oral bisphosphonates, we found that 60% receive at least 3 years of therapy when using an extended follow-up. Studies are needed to examine the benefits and harms of continuing bisphosphonate therapy beyond 3 years.

Factors Associated With Adherence to Osteoporosis Medications Among Male Veterans

Risk factors for nonadherence to osteoporosis medication have been well described for cohorts of women with osteoporosis, but little is known about predictors or mediators of nonadherence in men. We conducted a secondary analysis of a national cohort of male veterans to explore factors associated with nonadherence to osteoporosis medications. We included veterans with a prescription for an oral bisphosphonate or calcitonin between 2000 and 2010. We identified demographic, comorbid, and fracture-related risk factors by their International Classification of Diseases-9 (ICD-9) and Current Procedural Terminology (CPT) codes and used multivariable logistic regression to evaluate their association with adherence. Adherence was measured by medication possession ratio (MPR) over 5 years, starting at the time of their first prescription during the study period and censoring at death or end of study period. Of 135,306 men identified with at least one prescription for an osteoporosis medication during the study period, 90,406 (67%) were nonadherent (MPR < 0.80). The median duration of therapy was 3.2 years (interquartile range [IQR] = 1.7-5.0). In the fully adjusted model, the odds of adherence were lower in those aged <65 years (odds ratio [OR] = 0.87; 95% confidence interval [CI] 0.84-0.89), with no copay (OR = 0.78; 95% CI 0.76-0.80), dementia (OR = 0.87; 95% CI 0.83-0.91), anxiety/depression (OR = 0.92; 95% CI 0.90-0.95), tobacco use (OR = 0.91; 95% CI 0.89-0.94), alcohol abuse (OR = 0.91; 95% CI 0.89-0.94), rheumatoid arthritis (OR = 0.92; 95% CI 0.87-0.97), and on androgen deprivation therapy (OR = 0.89; 95% CI 0.83-0.95). The odds of adherence were higher in whites (OR = 1.14; 95% CI 1.11-1.17), with a prior screening colonoscopy (OR = 1.12; 95% CI 1.09-1.14), on alendronate versus other agents (OR = 1.61; 95% CI 1.55-1.67), with a dual-energy X-ray absorptiometry (DXA) (OR = 1.14; 95% CI 1.12-1.17), on glucocorticoids (OR = 1.08; 95% CI 1.02-1.14), and with recent fracture (OR = 1.07; 95% CI 1.04-1.10). In conclusion, adherence to oral bisphosphonates/calcitonin is poor, with particular subgroups at greatest risk. These findings may help tailor approaches for supporting adherence in men prescribed osteoporosis medications. © 2021 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.

Insufficient persistence of and adherence to osteoporosis pharmacotherapy in Japan

INTRODUCTION

Only a few large-scale studies have examined the care gap in Japan. The aim of this study was to investigate the persistence of and adherence to osteoporosis pharmacotherapy in Japan.

MATERIALS AND METHODS

The rates of continuation (persistence) of and adherence to osteoporosis pharmacotherapy were investigated using medical insurance data, issued from July 2013 to December 2018, from the medical care system for elderly individuals in Hokkaido, Japan.

RESULTS

The study included 7918 male and 52,585 female patients. Persistence rates were 62.1% in the first year and 45.3% in the second year. There were 33,096 patients who discontinued medication; 8296 patients resumed medication during the observation period of 730 days. The median time to the discontinuation of medication for all the patients was 702 days. The 2-year medication possession ratio (MPR) was 63.8%; 30,989 patients (51.2%) had an MPR ≥ 80% and 20,788 (34.4%) had an MPR < 50%. Both the persistence and adherence were better in females than in males and worsened with increasing age. Comparisons of fracture history showed that persistence and MPR were higher in the no hip or vertebral fracture group, followed by hip fracture, vertebral fracture, and hip and vertebral fracture groups. Meanwhile, more patients in the hip fracture group had an MPR ≥ 80%.

CONCLUSION

Persistence of and adherence to osteoporotic pharmacotherapy are not very high in Japan. To bridge the care gap following osteoporosis pharmacotherapy, improvements are required for males, the elderly, and those with a history of vertebral fracture.

Comparing the efficacies of bisphosphonates' therapies for osteoporosis persistence and compliance: A Systematic Review

OBJECTIVES

Osteoporosis is the most prevalent metabolic bone disorder worldwide. This review was undertaken to compare the efficacies of bisphosphonates therapies for patient persistence and compliance for the treatment of osteoporosis.

METHODS

A systematic review was performed in accordance with the available reporting items. MEDLINE and Cochrane library databases were applied for literature searched up to January 2020. All major studies such as prospective, retrospective and reviews articles that examined patient persistence or compliance to bisphosphonates for osteoporosis were included.

RESULTS

Literature search found 656 relevant published reports, out of which 87 were included. The 10,712,176 osteoporotic patients were studied for patient persistence and 5,875,718 patients were studied for patient compliances. Analysis of all studied bisphosphonates showed almost similar patterns for patient persistence rates as it was decreased over the time following initial prescription but persistence length was found to be significantly high for alendronate therapy as compared to the other studied bisphosphonates (p<0.001), whereas the length of persistence of all other bisphosphonates (other than alendronate) were almost same (p>0.05). Analysis of patient compliances with etidronate therapy showed the highest percent medication possession ratio (MRP) at 12 months, followed by the MRPs of ibandronate, alendronate, risedronate, and clodronate.

CONCLUSIONS

This is the first systematic review that shows the comparison of the efficiencies of bisphosphonates for patient persistence and compliance for the treatment of osteoporosis. The data showed that the length of patient persistence was highest for alendronate therapy, whereas patient compliance was highest for etidronate therapy for the treatment of osteoporosis.

Porous Bone Increases the Risk of Posterior Mandibular Implant Failure

PURPOSE

Our recent study indicated that patients with osteoporosis had an increased risk for early and late implant failure perhaps due to a large cancellous space. Therefore, the purpose of the article is to explore the relationship between the amount of cancellous space in an implant site and implant failure.

PATIENTS AND METHODS

The authors conducted a retrospective cohort study on patients who received dental implants in the posterior mandible at the senior author's practice from January 1, 2008 to October 1, 2019. The primary outcome variable was time to implant failure. The primary predictor variable was the amount of cancellous bone between the buccal and lingual cortices (cancellous space). Other study variables included demographic variables, medical history variables, and implant site measurements. Statistical analysis was performed using descriptive statistics, chi-squared tests, single variable and multiple Cox proportional hazard analyses.

RESULTS

The study cohort (n = 220) was composed of 62.3% women and the average age was 58.2 years. The median follow-up time was 3.5 years (range: 1-12). Five-year survival rates for patients with a cancellous space of <4 mm was 100%, with a cancellous space of 4-6 mm was 95.3%, with a cancellous space of 6-8 mm was 88.2%, and with a cancellous space of >8 mm was 64.1%. In the final multivariate Cox proportional hazard model adjusting for age, gender, smoking status, site and buccal cortex width, cancellous space remained significantly associated with time to implant failure (aHR 1.7 per millimeter change [1.4 - 2.2], P < .0001).

CONCLUSIONS

The width of the cancellous space and subsequent gap between implant and cortical bone should be considered when placing implants into the mandibular molar sites. When the patient presents for an implant in the mandibular molar region, if the cancellous space is large, the patient should be informed of the risk.

Extent of and reasons for osteoporosis medication non-adherence among veterans and feasibility of a pilot text message reminder intervention

We determined the extent of and reasons for non-adherence to oral bisphosphonates among veterans and conducted a pilot text message reminder application aimed at the most commonly cited reason for non-adherence. The intervention was found to be acceptable and feasible.

PURPOSE

To evaluate the extent of and reasons for non-adherence to oral bisphosphonates among veterans and to assess the acceptability and feasibility of a pilot text message reminder application.

METHODS

We surveyed 105 veterans initiating oral bisphosphonates for osteoporosis/osteopenia within the prior 18 months utilizing a validated self-report measure adapted for osteoporosis. Additionally, we conducted a pilot text message reminder to determine feasibility in 12 veterans who were initiating or were currently non-adherent to oral bisphosphonates.

RESULTS

Of the 43 (40.9% response rate) completed surveys, the most common reasons for non-adherence were "I forgot" (37.5%), "I had other medications to take" (20.5%), "my bones are not weak" (18.4%), "I felt well" (18.4%), and "I worried about taking them for the rest of my life" (17.9%). Median MPR for the 49 (46.7%) non-adherent (MPR < 0.80) veterans was 0.35 (IQR 0.21-0.64). Of veterans offered a weekly automated text message reminder, 12 (50%) accepted. Nine of these 12 veterans reported that the text message reminders did "very well" at reminding them to take their medication and would recommend the application to other patients/family/friends. The median 6-month MPR for the reminder group was 0.96 (IQR 0.54-1.00).

CONCLUSION

Half the veterans in our sample were taking insufficient doses of oral bisphosphonates to attain the full benefit of fracture risk reduction. Reasons for poor adherence included forgetfulness, polypharmacy, and misconceptions about osteoporosis. A pilot text message reminder intervention targeted to one of the most commonly cited reasons was found to be acceptable and feasible among veterans.

A novel effervescent formulation of oral weekly alendronate (70 mg) improves persistence compared to alendronate tablets in post-menopausal women with osteoporosis

BACKGROUND

A novel effervescent buffered solution of 70 mg alendronate (ALN-EX) was developed to improve upper gastrointestinal (GI) tolerability over alendronate tablets (ALN-T). Whether a better GI tolerability can improve persistence remains to be determined.

AIM

This study evaluated persistence and reasons for discontinuation in patients treated with ALN-EX compared to a historical cohort on ALN-T.

METHODS

Post-menopausal women (PMW) from a standardized clinical database with BMD T-score < -2.5, or between -2 and -2.5 and at least one vertebral fracture, starting ALN-EX between July 2015 and June 2016 were included. A historical cohort comprised of randomly selected and age-matched PMW on ALN-T was used as a control. Persistence at 6 and 12 months and reasons for discontinuation (e.g. adverse events; AE) were compared between the two groups.

RESULTS

A total of 144 PMW on ALN-EX and 216 PMW on ALN-T were analysed. Persistence at 6 and 12 months was 91% and 81% in the ALN-EX group vs. 75% and 69% in the ALN-T group, this difference attaining statistical significance at both 6- (p < 0.001) and 12 months (p = 0.009). A significantly higher proportion of patients receiving ALN-T discontinued treatment due to GI AEs (4% ALN-EX vs. 11% ALN-T; p = 0.027), or patient's decision to discontinue (6% ALN-EX vs. 13% ALN-T; p = 0.016). The adjusted odds ratio of persisting on ALN-EX treatment at 12 months was 2.02 (95% CI: 1.21-3.41, p = 0.008).

CONCLUSION

Our findings demonstrate that ALN-EX can provide greater persistence and improved tolerability compared to ALN-T, allowing it to be a viable alternative option in the management of osteoporosis.

Retrospective Analysis of the Effects of Non-Compliance with Denosumab on Changes in Bone Mineral Density During the COVID-19 Pandemic

PURPOSE

Although denosumab is a safe and effective treatment for osteoporosis in various clinical trials, few studies have investigated its efficacy in specific clinical situations. The effect of non-compliance with the standard six-month dosing regimen for denosumab on bone mineral density (BMD) was assessed in a retrospective study of patients prescribed denosumab during the COVID-19 pandemic.

PATIENTS AND METHODS

Between February 2019 and September 2020, 638 patient records were reviewed, with 236 patients meeting the eligibility criteria. Patients were divided into three groups: those who received denosumab injections between five and seven months after their initial subcutaneous injection, those who received denosumab injections between seven and nine months after their initial subcutaneous injection, and those who received denosumab injections more than nine months after their initial subcutaneous injection. A multivariate regression study was conducted to compare the BMD shift (at least one year apart) before and after two denosumab injections between the three pre-specified groups in both the lumbar spine (LS) and the femoral neck (FN).

RESULTS

The difference between LS BMD indicates that there is a statistical difference between subjects who received denosumab injections between 5 and 7 months (near-standard dosing interval) and more than 9 months (P=0.03), but not in FN BMD, and no clinically significant association was identified.

CONCLUSION

The results of this study show that in special clinical situations, such as the COVID-19 pandemic, clinicians may have some flexibility to prescribe denosumab, but the interval between injections should not exceed 9 months.

Irrational use of alendronate sodium by the elderly

Introduction: The effectiveness and safety of alendronate sodium are dependent on patient adherence to very specific guidelines regarding use. This study aims to estimate the rational use of alendronate sodium in the elderly. Methods: This is a cross-sectional study carried out with a structured questionnaire containing form of use and occurrence of adverse events related to alendronate sodium. The patients were recruited in their own homes. Rational use was considered as being the participants who: a) took the tablet in the morning; b) were fasting; c) waited at least 30 minutes before eating; d) ingested with a full glass of water; e) ingested the whole tablet; f) and remained in the orthostatic position for at least 30 minutes after use. Additionally, the odds ratio (OR) was used to analyze the association between the irrational use of alendronate sodium and the independent variables. Results and Discussion: Of the 248 participants in the study, most of the participants administered the medication in the morning (95.2%), with fasting (89.1%), waited at least 30 minutes to eat the first meal of the day (87.9%), and were in the orthostatic position until the time of the first meal (78.6%), but less than half ingested the tablet with a full glass of water (43.6%). Rational use of the medication was observed in only 30.7% of the participants. Regarding possible adverse events, 13.3% of the participants reported some event. Among the most prevalent were dry cough (6.5%), stomach pain (5.2%) and some throat discomfort (4.8%). The irrational use of this medication is associated with age and education level. Conclusion: The prevalence of irrational use of alendronate sodium in the elderly is high, and this use is associated with patients’ sociodemographic factors.

Bisphosphonate and denosumab initiation in older adults in Ontario, Canada: a population-based cohort study

We provide an update on how commonly prescribed osteoporosis therapies are being initiated in older adults in Ontario. Patients newly prescribed denosumab are older, more often female, and have more comorbidities than those prescribed bisphosphonates. Their characteristics, monitoring, and persistence with prescribed therapy differ from clinical trial participants. Real-world studies on oral bisphosphonates and denosumab might be valuable.

PURPOSE

To provide a contemporary view on oral bisphosphonate and denosumab prescribing to older adults in routine care.

METHODS

Using linked healthcare databases, we conducted a population-based cohort study of adults ≥ 66 years newly prescribed oral bisphosphonates or denosumab between February 2013 and March 2017 in Ontario, Canada. We captured their clinical characteristics, monitoring, and continuous use of prescribed therapies. We illustrate how "real-world" new users of bisphosphonates and denosumab differ from randomized controlled trial (RCT) participants.

RESULTS

There were 107,847 individuals newly prescribed oral bisphosphonates (n = 59,996) or denosumab (n = 47,851) over the study period. Compared with new users of oral bisphosphonates, denosumab users were older (mean age 79.1 vs. 75.7 years), more often female (97.2 vs. 71.8%), from non-rural areas (93.9 vs. 89.9%), and resided in long-term care (10.9 vs. 3.3%). They had more comorbidities including dementia, falls, and fractures. Following their new prescription, denosumab users had more frequent testing of serum calcium. Duration of continuous use of denosumab was longer than bisphosphonates, and more bisphosphonate users had evidence of treatment discontinuation (56.7 bisphosphonate vs. 33.8% denosumab users discontinued therapy at 365 days). Compared with RCT participants, a higher proportion of "real-world" bisphosphonate and denosumab users had comorbidities including advanced kidney disease.

CONCLUSION

The clinical characteristics and monitoring of new users of bisphosphonates and denosumab generally align with practice guidelines, product monographs, and drug reimbursement criteria. Given differences between real-world users and RCT participants, there may be a role for safety and effectiveness studies of bisphosphonates and denosumab in routine care.

Practical guidance for the use of bisphosphonates in osteoporosis

Bisphosphonates are widely used in the treatment of osteoporosis in postmenopausal women and older men. In clinical trials they have been shown to reduce fractures in women with osteoporosis and there is increasing evidence that they are also effective in women with osteopenia, in whom the majority of fractures occur. In addition to their role as initial therapy in individuals at increased risk of fracture, bisphosphonates are used as sequential therapy after treatment with anabolic drugs. There are no head-to head studies to compare the anti-fracture efficacy of different bisphosphonates, but there is limited evidence that zoledronate treatment results in greater increases in BMD than risedronate or alendronate. This, together with the need for less frequent administration of zoledronate, supports its wider use in clinical practice, particularly if longer dosing intervals than those currently recommended are shown to be effective.

The challenge of long-term adherence: The role of bone turnover markers in monitoring bisphosphonate treatment of osteoporosis

Oral Bisphosphonates (BPs) are the mainstay of osteoporotic treatment, however long-term adherence remains a challenge, primarily owing to the chronic character of the disease and the regimen complexity. Poor compliance has been shown to have a clear link to fracture risk. The role of bone turnover markers (BTMs) as a tool to ascertain adherence and response to therapy is supported by their rapid response to treatment; a decrease in values is witnessed within days or weeks of commencing treatment. A greater reduction of serum CTX and NTX is evidenced with alendronate and ibandronate compared to risedronate. A change in bone formation BTMs appears to be related to vertebral fracture risk reduction, whereas no significant relationship is evident for hip and non-vertebral fractures. The utility of BTMs as an adjunct for monitoring withdrawal of treatment with oral BP has also been suggested. Finally, studies evaluating BTMs as an intervention, failed to demonstrate any effect on adherence. This review explores the challenge of long-term adherence with bisphosphonates and provides an analytic framework with respect to the role of BTMs in monitoring bisphosphonate treatment, adherence and the offset of treatment effect.

Outcome of osteoporosis evaluation, treatment, and follow-up in patients referred to a specialized outpatient clinic compared to patients in care of general practitioners

In Denmark, osteoporosis treatment is either handled by general practitioners or at more resource demanding specialist clinics. We evaluated the treatment adherence and persistence in the two settings, which were overall similar. The type of medical support did, however, differ and was provided to two very different patient populations.

PURPOSE

The study aimed to investigate the effect of patient care by general practitioners (GPs) or specialists on treatment adherence among osteoporosis patients initiating treatment with oral bisphosphonates (OB).

METHODS

Dual-energy X-ray absorption (DXA)-scanning data from 2005 to 2013 were extracted. Treatment naïve patients with a T-score ≤ - 2.5 (spine or hip) were included. Information on medical treatment, comorbidities, and socio-economic status was extracted from Danish registries. Scanning results were evaluated by a specialist. Subsequent treatment initiation and follow-up was either handled by GPs or specialists: GP population (GPP) vs. specialist population (SP). Primary adherence was defined as treatment initiating within 12 months from diagnosis and secondary adherence as days with medicine possession rates (MPR) > 80%.

RESULTS

Of 11,201 DXA-scanned patients, 3685 met the inclusion criteria (GPP = 2177, SP = 1508). The GPP consisted of relatively more men, was older, had shorter education, lower income, and more comorbidities. There was no difference in baseline T-score or prior incidence of major osteoporotic fractures (MOFs). The GPP was primarily treated with OB and had better primary adherence (adjusted OR_GPP/SP = 1.52 [1.31-1.75], p < 0.0001) than the SP that to a higher degree received another treatment. Secondary adherence was similar (adjusted OR_GPP/SP: OR_{12 months} = 1.02 [0.83-1.26]; OR_{24 months} = 0.90 [0.73-1.10]; OR_{4 years} = 0.88 [0.71-1.07]; OR_{5 years} = 0.91 [0.74-1.13].

CONCLUSION

Patients in care of specialists were most likely to receive a treatment other than OB. Primary adherence was highest in the GPP, whereas short- and long-term persistence was similar for up to 5 years whether treated by a specialist or a GP.

A Mixed Methods Study Exploring Older Womens' Attitudes Toward Osteoporosis Medications: Adapting a Health Communication Framework

Background: Bisphosphonates (BPs) can reduce fracture risk for adults with osteoporosis (OP), but they have rare risks, complicating decision making. Guided by an established health decision and communication framework, we explored older women's feelings and positions toward taking BPs. Materials and Methods: Using a mixed-methods design, we interviewed women >65 years of age who had never taken BPs. After learning about BPs, participants responded to items about their feelings toward medication benefits/risks. They then identified their overall position toward taking BPs (corresponding to Unquestioning Acceptors, Cautious Acceptors, Hesitants, Probable Refusers, and Definite Refusers). We analyzed data using qualitative content analysis and summarized quantitative data with descriptive statistics. Results: Thirty women participated. Acceptors (N = 17, 56.6%) worried about OP-related fractures. Hesitant participants (N = 12, 40%) worried about BP risks, yet expressed openness toward medications if given opportunities to gather information and talk to clinicians. One Refuser expressed distrust in clinicians and pharmaceuticals. Conclusions: Understanding women's positions toward BPs might improve decision-making processes for OP treatment. Clinicians could tailor communication based on patients' identified BP position. Acceptors might be comfortable with succinct conversations describing medications. Hesitant patients might need more information from resources such as decision aids. Building trust with patients questioning BPs can support future conversations.