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Higher fracture risk linked to poor persistence with osteoporosis drugs

Independent studies of patients in Belgium, Canada, and Germany confirm that there is a major gap in treating patients with osteoporosis, despite the availability of a wide range of drugs, supplements and practices that help maintain and even build bone strength.
Together, the studies demonstrate that osteoporosis is widely under diagnosed and under treated. Also troubling is the revelation that the majority of patients who are prescribed suitable medication stop taking the drugs prematurely.

Osteoporosis; under recognized and under treated

Susan Jaglal, University of Toronto, and colleagues evaluated follow up care practices at five communities in the province of Ontario and found that the majority of patients treated for low trauma fracture are not adequately screened for osteoporosis and receive poor quality care.

Low trauma fractures are caused by a force that would usually not break a bone, such as a fall from a standing position. These fractures are an important indication of osteoporosis and potentially a future, more debilitating fracture. " It is crucial that individuals who have sustained a low-trauma fracture follow-up with their family physician to investigate the possibility of osteoporosis," said Jaglal.

But her research indicates that among 125 patients who had a low-trauma fracture of the wrist, hip, spine, or shoulder in 2003, 63% had no known history of osteoporosis. Of those patients, 61 percent had not received a bone density scan since their fracture. A bone density scan is a quick and simple test for osteoporosis.

The majority of patients in this sample, whether they had previously been diagnosed with osteoporosis or not, also reported not receiving any information on the disease or its management. They were not told, for example, to increase their vitamin D or calcium intake or to take part in an exercise program, practices that are known to help maintain bone strength. Of those patients who had been diagnosed with osteoporosis, however, 85 percent had been prescribed a suitable medication.

The Canadian findings were echoed by researchers in Germany. Burkhard Dasch and colleagues at the University of Bochum reported a similar study on postmenopausal women who suffered minimal trauma fractures of the wrist. Dasch reported that out of 761 women who suffered such a fracture during the 21 months after December 2001, only 24 ( less than 4 percent ) were given a bone density scan and only 62 ( less than 10 percent ) were advised to take supplemental calcium or vitamin D.

Osteoporosis medication was only prescribed for 72 of the patients ( 9.5 percent ) and in follow up interviews Dasch and colleagues found that 20 patients had experienced another fracture. Despite the availability of effective treatments, a substantial portion of postmenopausal women are not being adequately treated or evaluated for possible osteoporosis, conclude the researchers.

In fact, researchers in Belgium have come to the dramatic conclusion that having osteoporosis makes no difference to the likelihood that elderly women will be prescribed treatments to protect their bones. Florent Richy and colleagues at the University of Liège studied prescription patterns among nearly two thousand post-menopausal women who were treated at a Liège outpatient clinic between 1996 and 1999. The researchers found that almost two thirds of osteoporosis-free patients were prescribed bone-building dietary supplements and/or one of several types of osteoporosis drug. Surprisingly, prescription rates among patients with osteoporosis were about the same.

The researchers examined what kind of medication or supplements were most often prescribed. Calcium, together with vitamin D, dietary nutrients that are essential for building and maintaining bone, were most common, but prescriptions for the combination were only written for 34 percent of osteoporosis patients. Next, doctors were most likely to prescribe bisphosphonates in combination with either vitamin D or calcium. But only 21 percent of patients received the vitamin/bisphosphonate therapy, while only 7 percent were given a bisphosphonate in combination with calcium. Among osteoporosis-free women, just over 40 percent received hormone replacement therapy, which is known to help maintain bone strength, but only 11 percent of those women were put on vitamin D and calcium supplements.

Overall this study, one of the first to analyze prescription patterns among women with and without osteoporosis, shows that both treatment and preventative measures among Belgium women are woefully inadequate. Given that Belgium is one of the leaders in osteoporosis treatment and diagnosis, having more bone density measuring equipment per capita than any other country and a strong social insurance system, the findings do not bode well for the rest of the world either.

Persistence problems

Sylvie Perreault and colleagues from the University of Montreal, Quebec, reported that persistence--the proportion of patients, who keep taking their medication, can be less than 50 percent.
The good news is that patients are more likely to keep up with prescriptions for once-weekly bisphosphonates than for pills that must be taken daily. But around 35 percent of patients stop taking the once-a-week medication within a year.

Lead author Julie Blouin and colleagues collated data from the Quebec health insurance administrative database ( Regie de l'Assurance Maladie du Quebec ).
They examined what kind of medicine was prescribed and how diligently those prescriptions were filled during two time periods, 1998-2001 and 2002-2004.
During the first time period only daily bisphosphonates were available.
Bisphosphonates that can be taken once-weekly became available in 2002.

The researchers analyzed prescription patterns for almost 13,000 women who were prescribed several different types of bone antiresorptive therapy, including bisphosphonates; the hormone calcitonin, which helps build bone; and raloxifene, an estrogen mimic that helps maintain bone.

The authors found that the once-weekly bisphosphonate became the mainstay for osteoporosis therapy after 2002, accounting for almost 85 percent of all prescriptions for osteoporosis ( up from 60 percent in years when these drugs were only available in daily form ). Blouin found that after one year of treatment, almost 65 percent of patients were still taking the once-weekly bisphosphonates. But persistence in women taking daily bisphosphonate, calcitonin, or Raloxifene ( Evista ) was as low as 45 percent.

The researchers also found that patients who had a bone density scan before or during their treatment had a much lower risk of stopping their medication, suggesting that routine monitoring of bone mineral density may spur patients to keep up with their treatment. Curiously, women visiting different pharmacies or physicians had a higher risk of stopping treatment, suggesting that health care providers are either unaware of or fail to emphasize the seriousness of osteoporosis.

Osteoporosis patients who discontinue their medication are putting themselves at increased risk for bone fracture. " Our results emphasize the necessity to evaluate the impact of non-optimal use of antiresorptive therapies on clinical issues such as the incidence of osteoporotic fracture”, said Blouin.

All told these findings have serious implications for worldwide efforts to protect people at risk from life-threatening and debilitating bone fractures. Osteoporosis, often called the "silent killer," is estimated to strike one in three women and one in five men. The disease dramatically increases the risk of sustaining a major bone fracture and is a prime cause of morbidity, mortality, and immobility in the elderly.

Source: International Osteoporosis Foundation, 2006