Low Bone Mineral Density and Calcium Levels as Risks for Mortality in Patients with Self-Discontinuation of Anti-Osteoporosis Medication

Bone mass density (BMD) has been used universally in osteoporosis diagnosis and management. Adherence to anti-osteoporosis medication is related to mortality risk. This study aimed to investigate the relationship between mortality and low BMD of the femoral neck and vertebra among patients self-discontinuing anti-osteoporosis medication. Between June 2016 and June 2018, this single-center retrospective study recruited 596 participants who self-discontinued anti-osteoporosis medication. Patients were categorized into four groups by BMD of the right femoral neck and lumbar spine. Occurrence and causes of mortality were obtained from medical records. Independent risk factors and the five-year survival of various levels of BMD were analyzed by Cox regression and the Kaplan–Meier survival analysis. BMD value and serum calcium level were significantly lower in the mortality group (p < 0.001). Compared to the reference, the adjusted hazard ratio (HR) for all-cause mortality in patients with lower BMD of both the lumbar spine and femoral neck was 3.03. The five-year cumulative survival rate was also significantly lower (25.2%, p < 0.001). A low calcium level was also associated with mortality (HR: 0.87, 95% CI: 0.76–0.99, p = 0.033). In conclusion, lower BMD and calcium levels were associated with higher mortality risk in patients with poor adherence. Hence, patients self-discontinuing anti-osteoporosis medication should be managed accordingly.

Improvement of osteoporosis Care Organized by Nurses: ICON study - Protocol of a quasi-experimental study to assess the (cost)-effectiveness of combining a decision aid with motivational interviewing for improving medication persistence in patients with a recent fracture being treated at the fracture liaison service

Background Given the health and economic burden of fractures related to osteoporosis, suboptimal adherence to medication and the increasing importance of shared-decision making, the Improvement of osteoporosis Care Organized by Nurses (ICON) study was designed to evaluate the effectiveness, cost-effectiveness and feasibility of a multi-component adherence intervention (MCAI) for patients with an indication for treatment with anti–osteoporosis medication, following assessment at the Fracture Liaison Service after a recent fracture. The MCAI involves two consultations at the FLS. During the first consultation, a decision aid is will be used to involve patients in the decision of whether to start anti-osteoporosis medication. During the follow-up visit, the nurse inquires about, and stimulates, medication adherence using motivational interviewing techniques. Methods A quasi-experimental trial to evaluate the (cost-) effectiveness and feasibility of an MCAI, consisting of a decision aid (DA) at the first visit, combined with nurse-led adherence support using motivational interviewing during the follow-up visit, in comparison with care as usual, in improving adherence to oral anti-osteoporosis medication for patients with a recent fracture two Dutch FLS. Medication persistence, defined as the proportion of patients who are persistent at one year assuming a refill gap < 30 days, is the primary outcome. Medication adherence, decision quality, subsequent fractures and mortality are the secondary outcomes. A lifetime cost-effectiveness analysis using a model-based economic evaluation and a process evaluation will also be conducted. A sample size of 248 patients is required to show an improvement in the primary outcome with 20%. Study follow-up is at 12 months, with measurements at baseline, after four months, and at 12 months. Discussion We expect that the ICON-study will show that the MCAI is a (cost-)effective intervention for improving persistence with anti-osteoporosis medication and that it is feasible for implementation at the FLS. Trial registration This trial has been registered in the Netherlands Trial Registry, part of the Dutch Cochrane Centre (Trial NL7236 (NTR7435)). Version 1.0; 26-11-2020.

The Trend in the Sales of Menopausal Hormone and Other Osteoporosis Medications in South Korea from 2016 to 2019

Background: Increasing geriatric population, osteoporosis prevalence, and interest in bone health are key contributing factors for the growth of osteoporosis medication markets. Thus, this study evaluated changes in the menopausal hormone and other osteoporosis medication markets from 2016 to 2019.Methods: This study’s dataset was obtained from the International Marketing Services of IQVIA Inc. in South Korea. The sales of medications for osteoporosis treatment with menopausal hormones were evaluated for drug sales for osteoporosis treatment from 2016 to 2019.Results: The results showed that the tissue-selective estrogen complex (TSEC) sales had increased annually while the estrogen-progesterone therapy (EPT) sales had decreased. Excluding menopausal hormones, bisphosphonates were the most widely sold medications for osteoporosis treatment. Among the bisphosphonate medications, sales of ibandronate and zoledronate increased annually, while alendronate and risedronate decreased. Teriparatide also showed increasing sales. A rapid rise was noted in the sales of denosumab.Conclusions: While the sales of TSEC, injectable bisphosphonates, and denosumab have increased annually, the sales of EPT, estrogen therapy, oral bisphosphonates have not increased, as reflected in hormone therapy and osteoporosis medication market trends. This study showed the recent trends in hormone therapy and the osteoporosis medication market from 2016 to 2019 in South Korea.

AB0618 GLUCOCORTICOID INDUCED OSTEOPOROSIS PREVENTION IN THE OUTPATIENT RHEUMATOLOGY CLINIC

Background:Patients with rheumatic disease are at risk of developing glucocorticoid induced osteoporosis (GIOP) as many are prescribed systemic oral glucocorticoids as an adjunct to their maintenance therapy. Based on the 2017 ACR Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis, a good practice recommendation exists that “initial clinical fracture risk assessment should be performed as soon as possible, but at least within six months of the initiation of long term glucocorticoid treatment.1” Long-term glucocorticoid use is defined by duration of 3 months or greater. Fracture risk assessment should include dual energy-ray absorptiometry (DEXA) scan. Patients on greater than or equal to 2.5 mg of prednisone should be treated with an optimal dose of calcium and vitamin D and may benefit from oral bisphosphonate as primary prevention against GIOP if their fracture risk is moderate to high.1Objectives:The aim of this Quality Improvement Project is to assess the current status of provider implementation of GIOP recommendations in the rheumatology clinic. Ultimate goal is to improve osteoporosis prevention in the rheumatology clinic.Methods:We conducted a retrospective chart review of 60 patients in two outpatient rheumatology clinics. Clinic 1 follows patients with lower socioeconomic status and Clinic 2 follows patients with higher socioeconomics. Inclusion criteria were patients on long-term glucocorticoid use, defined as at least 3 months of corticosteroid use of at least 2.5 mg prednisone daily, as well as age less than 65. Females aged 65 or older were omitted to prevent overlap of the United States Preventative Taskforce recommendation for all women ≥ 65 years to be screened for osteoporosis with DEXA scans.2 DEXA scan orders, calcium and vitamin D prescriptions, and osteoporosis medication prescriptions were abstracted. After baseline data obtained, intervention of education of the rheumatology fellows and faculty, and internal medicine residents in the guidelines for GIOP prevention was implemented. In addition, a smartphrase in the electronic medical record was created for provider use when treating patients on chronic corticosteroids. Subsequently, two audit cycles were completed for retrospective chart review.Results:Upon completion of second audit cycle, there was no change in percentage of DEXA scan orders at Clinic 1, however there was a 10% overall improvement in DEXA scan orders in the Clinic 2.In terms of Calcium and Vitamin D prescriptions, there was an overall improvement in both clinics of 19.7% and 13.3% in Clinics 1 and 2 respectfully after the second audit cycle.Additionally, there was a 3.4% increase in osteoporosis medication prescriptions overall subsequent to the second audit cycle in Clinic 1. However in Clinic 2 there was an overall decrease in osteoporosis medication prescriptions of 6.6%.Clinic 1Prior to AuditAudit cycle 1Audit cycle 2Patient percentage without DEXA scan orders30%33.30%30%Patient percentage without Vitamin D/Calcium orders26.40%8.30%6.70%Patient percentage with osteoporosis medication orders23.30%8.30%26.70%Clinic 2Patient percentage without DEXA scan orders50%37.00%40%Patient percentage without Vitamin D/Calcium orders30%26.00%16.70%Patient percentage with osteoporosis medication orders23.30%11.10%16.70%Conclusion:Overall, the results of the intervention were strongest for improvements in Vitamin D and Calcium orders in both clinics. Improvements in DEXA scan orders and osteoporosis medications were present in Clinic 2 and not present in Clinic 1. This reveals continued efforts and education of providers need to be made for improvement in bone health monitoring.References:[1]Buckley, Lenore, et al. “2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis.” Arthritis & Rheumatology, vol. 69, no. 8, June 2017, pp. 1521–1537., doi:10.1002/art.40137.[2]Final Recommendation Statement: Osteoporosis to Prevent Fractures: Screening. U.S. Preventive Services Task Force. July 2019.Disclosure of Interests:None declared.

Osteoporosis Care After Hip Fracture: A Regional Healthcare System Experience

Background: Pharmacologic treatment is recommended to reduce risk of future fractures and possibly reduce mortality in patients with hip fracture. We investigated osteoporosis care after hip fracture at a regional comprehensive healthcare system to identify rates of pharmacologic treatment after hip fracture and barriers to treatment. Methods: We identified all patients admitted with a low impact hip fracture between 1/2017-12/2018. Follow-up clinical data was collected for a minimum of 16 months after hip fracture. Results: 208 patients were admitted with low impact hip fractures: 130 (62%) were female, mean age was 79.6 (SD 12.6), 24 (12%) were nursing home resident, and 117 (56%) had BMI &lt;25 kg/m2. At the time of the fracture, 80% had polypharmacy, 42% used mobility aide, 24% had known osteoporosis, 22% had dementia/cognitive impairment, 20% has history of cancer, 20% had history of stroke, 19% had diabetes and 2% were on dialysis. Two hundred (96%) underwent surgery. Forty-three (20%) had vitamin D level checked, of this, 20 (46%) had level &lt;30 ng/mL. Prior to admission prescription of vitamin D was 53% and calcium was 36%. Discharge prescription of vitamin D was 64% and calcium was 50%. Prior to fracture, 18/208 (9%) were prescribed osteoporosis medication and at 1 year following fracture, 26/192 (14%) were prescribed osteoporosis medication (11 new, 15 continuation of medication). For follow up, 114/192 (59%) were seen in orthopedics clinic, 61 (32%) in primary care clinic, 2 (1%) in endocrinology clinic and 99 (52%) in other clinics. Sixteen (8%) patients died during the hospitalization for hip fracture and 47 (22%) died within 1 year. Conclusions: Osteoporosis treatment after hip fracture is suboptimal and a model of care is needed to close this care gap.

Retrospective analysis of the use of osteoporosis medication at the presentation of non-vertebral fragility fractures in a predominantly Hispanic population.

Background: Despite the high incidence of osteoporosis, many patients at risk of fragility fractures may not initiate treatment due to concerns about side effects, cost or under-diagnosis, such as the case of vertebral fractures. We aimed to identify whether the patient population with non-vertebral fragility fractures where already receiving prophylactic treatment for osteoporosis at presentation within a regional hospital in the southernmost region of the United States. This region is characterized by a high number of patients from Hispanic/Latino heritage (80%) and reduced access to healthcare services. Methods: We conducted a three-year, retrospective cohort study of patients presenting with low impact fractures of the humerus or the shoulder griddle, lower end of radius or ulna and forearm, hip fractures (femoral neck, intertrochanteric/ subtrochanteric), and ankle fractures. Male and female subjects of 50 years or older were included. Demographic data and information on medications reported at fracture presentation were extracted from electronic medical records. Results: We found that 42% of the patients were taking at least one medication to prevent osteoporosis. The predominant combination was vitamin D plus calcium and bisphosphonates. If patients taking only vitamin D plus calcium are excluded, 16.7% of the sample took osteoporosis medications at the fragility fracture presentation. The likelihood of taking osteoporosis medication was increased by age and type of health insurance (Medicare/private insurance), and concomitant diagnosis of impaired gait and mobility. The percentage of the patients taking prophylactic medications for osteoporosis at the time of a fragility fracture was comparable to reported national standards and associated with increased age and health insurance coverage. Conclusion: In a predominantly Hispanic/Latino patient population living in a medically underserved region, there is substantial recognition and prevention strategies for osteoporosis.