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Yavropoulou MP, Kasdagli MI, Makras P, Diomatari KM, Anastasilakis AD, Mitsikostas DD, Kassi E, Sfikakis PP, Kravvariti E. Nocebo-associated treatment discontinuation with subcutaneous anti-osteoporotic drugs. A systematic review and meta-analysis of placebo-arm dropouts in randomized-controlled trials. Maturitas 2024; 179:107874. [PMID: 37976923 DOI: 10.1016/j.maturitas.2023.107874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 09/22/2023] [Accepted: 10/24/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE Nocebo is a concept of therapeutics referring to unpleasant symptoms attributed by a patient to a drug, due to negative anticipation. Patients receiving oral anti-osteoporotic drugs in randomized controlled trials (RCT) can experience adverse events leading to dropout, implying that nocebo contributes to treatment discontinuation for these drugs. In this study we aim to investigate the nocebo effect of subcutaneous anti-osteoporotic drugs with a higher compliance rate than orally administered drugs. STUDY DESIGN We searched MEDLINE, EMBASE, SCOPUS, and Cochrane databases for double-blind trials investigating subcutaneous anti-osteoporotic drugs for osteoporosis (namely, denosumab, teriparatide, abaloparatide and romosozumab) published up to May 2023. MAIN OUTCOME MEASURE Dropouts due to reported adverse events in the placebo arms ("nocebo dropouts"). RESULTS Data from 17 trials were extracted. Among 10,529 placebo-treated patients the pooled nocebo-dropout percentage was 3 % for denosumab (average: 0.03; 95 % CI: 0.01-0.05), 1 % for romosozumab (average: 0.01; 95 % CI: 0.00-0.03) and 6 % for teriparatide and abaloparatide (average: 0.06; 95 % CI: 0.05-0.07). Nocebo-dropouts were significantly higher in men than women (6 % vs. 3 %, respectively, p = 0.012), in older (mean age >68 years) than in younger patients (5 % vs. 1 %, respectively, p = 0.017) and in those with more severe osteoporosis (based on the percentage of participants with prior fragility-related fractures in the study cohort) compared with patients with no prior fracture history (4 % vs. 1 %, respectively, p = 0.046). CONCLUSION Nocebo responses may contribute to treatment discontinuation with subcutaneous anti-osteoporotic drugs in clinical practice. Higher nocebo-related dropout rates in the higher-risk RCT population (older patients, males, those with prior fractures) show that nocebo mechanisms have the potential to hinder therapeutic efforts to specific populations who would benefit most. Prospero registration number CRD42020212843.
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Affiliation(s)
- Maria P Yavropoulou
- Endocrinology Unit, 1st Department of Propaedeutic and Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Laikon University Hospital of Athens, 11527 Athens, Greece.
| | - Maria-Iosifina Kasdagli
- Department of Hygiene and Epidemiology, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Polyzois Makras
- Department of Medical Research, 251 Hellenic Air Force & VA General Hospital, Athens, Greece
| | - Konstantina-Maria Diomatari
- Postgraduate Medical Studies in the Physiology of Aging and Geriatric Syndromes, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | | | - Dimos D Mitsikostas
- 1st Neurology Department, Aeginition Hospital, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Eva Kassi
- Endocrinology Unit, 1st Department of Propaedeutic and Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Laikon University Hospital of Athens, 11527 Athens, Greece
| | - Petros P Sfikakis
- Endocrinology Unit, 1st Department of Propaedeutic and Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Laikon University Hospital of Athens, 11527 Athens, Greece; 1st Department of Propaedeutic and Internal Medicine, Joint Academic Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Laikon University Hospital of Athens, 11527 Athens, Greece
| | - Evrydiki Kravvariti
- Endocrinology Unit, 1st Department of Propaedeutic and Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Laikon University Hospital of Athens, 11527 Athens, Greece; 1st Department of Propaedeutic and Internal Medicine, Joint Academic Rheumatology Program, School of Medicine, National and Kapodistrian University of Athens, Laikon University Hospital of Athens, 11527 Athens, Greece
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Alahmari MM, AlHilali AI, Thabet TA, Alshahrani MA, Mobasher WA, Al Mubarak DA, Alshamrani AM, Gohman RS, Alqarni SA, Alqahtani MM. Impact of Medication Adherence on Bone Mineral Density and Fracture Risk in Patients With Osteoporosis: A Systematic Review. Cureus 2023; 15:e42115. [PMID: 37602050 PMCID: PMC10436998 DOI: 10.7759/cureus.42115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2023] [Indexed: 08/22/2023] Open
Abstract
Osteoporosis is a chronic, prevalent disease marked by decreased bone mass and changes in bone anatomy associated with significant morbidity. The management of osteoporosis necessitates long-term therapy for which patient adherence is of vital importance. In the present review, we aim to collect all potential evidence from relevant studies that reported the impact of medication adherence on bone mineral density and fracture risk in patients with osteoporosis. We have conducted both electronic and manual search strategies within the potential databases and included articles and reviews to find relevant studies. We have assessed the effects of osteoporotic medication adherence on fracture rates and bone mineral density. The study participants were divided into two groups, adherent and non-adherent. Studies from the year 2010-2023 were included. Final inclusion consisted of 14 studies that showed variation in adherence rates with only three studies reporting optimal adherence followed by two studies with nearly half adherent population while the rest of the studies reported low medication adherence. The highest adherence rate reported was 82% while the lowest was 8%. Among the included studies the fracture rates varied significantly. Decreased rates of fracture were observed in the adherent population however two of the included studies were contrary to these findings. Additionally, only three studies discussed the effect of adherence on bone mineral density. Lack of medication adherence is linked to an increased risk of fracture, and low bone mineral density, further associated with more severe complications as per the evidence from the literature. However, variation in the fracture rates as observed in our findings advocates the need for further research for the generalizability of results.
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Affiliation(s)
- Manea M Alahmari
- Department of Endocrinology and Diabetes, Muhayel General Hospital, Muhayel, SAU
| | - Ali I AlHilali
- Department of Endocrinology and Diabetes, Aseer Central Hospital, Abha, SAU
| | - Taef A Thabet
- Department of Internal Medicine, Aseer Central Hospital, Abha, SAU
| | | | | | | | - Abdullah M Alshamrani
- Department of Endocrinology and Diabetes, Armed Forces Hospital Southern Region, Khamis Mushait, SAU
| | - Raghad S Gohman
- Department of Internal Medicine, Aseer Central Hospital, Abha, SAU
| | - Seham A Alqarni
- Department of Internal Medicine, Aseer Central Hospital, Abha, SAU
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Mochizuki T, Yano K, Ikari K, Okazaki K. Comparison of different parameters between daily and twice-weekly teriparatide in postmenopausal women with severe osteoporosis. J Bone Miner Metab 2023; 41:220-226. [PMID: 36625920 DOI: 10.1007/s00774-022-01398-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/23/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Once-daily teriparatide (D-TPTD) and twice-weekly TPTD (W-TPTD), which are self-administered injections, are generally used in the treatment of severe osteoporosis. This study aimed to reveal the differences in the persistence, safety, and effectiveness of D-TPTD and W-TPTD. MATERIALS AND METHODS A total of 102 patients received D-TPTD (n = 51) and W-TPTD (n = 51). The bone mineral densities (BMD) of the lumbar spine, total hip, and femoral neck were measured using dual energy X-ray absorptiometry. The persistence and effectiveness of the two treatments were compared at 12 months. RESULTS The persistence in the D-TPTD and W-TPTD groups was 80.4% and 66.7% at 12 months, respectively (p = 0.178). The % changes (Δ) in BMD values from baseline for the lumbar spine in the D-TPTD were significantly higher than those in the W-TPTD (11.2% vs. 6.3%; p < 0.001) at 12 months. The ΔBMD values for the total hip (3.7% vs. 1.3%; p = 0.065) and femoral neck (2.2% vs. 1.6%; p = 0.489) did not differ significantly between the two groups at 12 months. The incidence of new morphological vertebral fractures in the D-TPTD and W-TPTD groups was 7.3% and 8.6%, respectively, at 12 months (p = 1.000). CONCLUSIONS Lumbar spine BMD (LS-BMD) was significantly increased. Moreover, ΔLS-BMD in the D-TPTD group was higher than that in the W-TPTD group. This study showed that the persistence, ΔTH-BMD, ΔFN-BMD and incidence of vertebral fractures did not differ between the two groups.
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Affiliation(s)
- Takeshi Mochizuki
- Department of Orthopedic Surgery, Kamagaya General Hospital, Kamagaya, Chiba, Japan.
| | - Koichiro Yano
- Department of Orthopedic Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Katsunori Ikari
- Department of Orthopedic Surgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Ken Okazaki
- Department of Orthopedic Surgery, Tokyo Women's Medical University, Tokyo, Japan
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McConnell M, Shieh A. Polypharmacy in Osteoporosis Treatment. Clin Geriatr Med 2022; 38:715-726. [DOI: 10.1016/j.cger.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Association between P1NP and bone strength in postmenopausal women treated with teriparatide. Taiwan J Obstet Gynecol 2022; 61:91-95. [PMID: 35181054 DOI: 10.1016/j.tjog.2021.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate the association between P1NP and bone strength in postmenopausal women treated with teriparatide. MATERIALS AND METHODS This prospective study enrolled 248 postmenopausal women with severe osteoporosis treated with teriparatide. Procollagen type 1 N-terminal propeptide (P1NP) were assessed at baseline, 3, 6, and 12 months. Lumbar spine (LS), femoral neck (FN), and total hip (TH) bone mineral density (BMD) and LS trabecular bone score (TBS) were measured by Dual-energy x-ray absorptiometry at baseline and 12 months. RESULTS With teriparatide use, P1NP levels increase and peaked at 6 months. Significant increase in LS and hip BMD and LS TBS were also noted. The percentage change or absolute change >10 μg/L in PINP at 3 months was only related to changes in LS BMD at 12 months. With a median baseline P1NP level was 65.5 ng/mL, we found no correlation between P1NP and LS and hip BMD nor LS TBS. There was no association between LS TBS and axial BMD. After treatment, there was also no significance between the changes in TBS and axial BMD. Over the study period, 83.9% of the 248 participants were persistent with teriparatide at 3 months, 77.8% at 6 months, and 67.3% women at 12 months. CONCLUSION P1NP levels may provide a signal of osteoporosis risk but is not related to bone strength. Early changes in P1NP may offer information regarding subsequent BMD response so standardized monitoring of P1NP levels at baseline and at 3 months should be considered during osteoporosis therapy. As an additional benefit, serum level monitoring during treatment may also improve medication persistence.
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Chen CH, Elsalmawy AH, Ish-Shalom S, Lim SJ, AlAli NS, Cunha-Borges JL, Yang H, Casas N, Altan L, Belaya Z, Marin F, Moll T, Gurbuz S, Brnabic A, Pavo I, Florez S. The Effect of Teriparatide Treatment on the Risk of Fragility Fractures in Postmenopausal Women with Osteoporosis: Results from the Asian and Latin America Fracture Observational Study (ALAFOS). Calcif Tissue Int 2022; 110:74-86. [PMID: 34415388 PMCID: PMC8732800 DOI: 10.1007/s00223-021-00895-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/20/2021] [Indexed: 01/04/2023]
Abstract
The Asian and Latin America Fracture Observational Study (ALAFOS) is a prospective, observational, single-arm study conducted in 20 countries across Asia, Latin America and the Middle East. ALAFOS evaluated new clinical vertebral and non-vertebral fragility fractures in relation to time on teriparatide, in postmenopausal women with osteoporosis in real-life clinical practice. Clinical fragility fractures, back pain, and health-related quality of life (HRQoL) were recorded in 6-month intervals for ≤ 24 months during teriparatide treatment and up to 12-months post-treatment. Data were analysed with piecewise exponential regression with inverse probability weighting for time to event outcomes and mixed-model repeated measures for back pain and HRQoL. 3054 postmenopausal women started teriparatide and attended ≥ one follow-up visit (mean [SD] age 72.5 [10.4] years). The median (95% CI) time to treatment discontinuation was 22.0 months (21.2, 22.8). During the treatment period, 111 patients (3.6%) sustained 126 clinical fractures (2.98 fractures/100 patient-years). Rates of new clinical fragility fractures were significantly decreased during the > 6-12, > 12-18, and > 18-24-month periods, as compared with the first 6 months of treatment (hazard ratio [HR] 0.57; 95% CI 0.37, 0.88; p = 0.012; HR 0.35; 95% CI 0.19, 0.62; p < 0.001; HR 0.43; 95% CI 0.23, 0.83; p = 0.011; respectively). Patients also reported an improvement in back pain and HRQoL (p < 0.001). These results provide data on the real-world effectiveness of teriparatide in the ALAFOS regions and are consistent with other studies showing reduction of fractures after 6 months of teriparatide treatment. These results should be interpreted in the context of the noncontrolled design of this observational study.
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Affiliation(s)
- Chung-Hwan Chen
- Department of Orthopedics and Orthopedic Research Center, Kaohsiung Municipal Ta-Tung Hospital and Kaohsiung Medical University Hospital, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Regeneration Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Abdulaziz H Elsalmawy
- Department of Trauma and Orthopedic Surgery, Al Noor Specialized Hospital Makkah, Mecca, Saudi Arabia
| | | | - Seung-Jae Lim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Nadia S AlAli
- Endocrinology Unit, Amiri Hospital, MOH, Kuwait City, Kuwait
| | | | - Huilin Yang
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou, People's Republic of China
| | | | - Lale Altan
- Department of Physical Medicine and Rehabilitation, Uludağ University School of Medicine, Bursa, Turkey
| | - Zhanna Belaya
- Department of Neuroendocrinology and Bone Disease, The National Medical Research Center for Endocrinology, Moscow, Russia
| | | | | | | | | | - Imre Pavo
- Eli Lilly and Company, Indianapolis, USA
| | - Sandra Florez
- Eli Lilly and Company, Indianapolis, USA.
- Pain and Palliative Care Department, Universidad de la Sabana, Chía, Colombia.
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Jácome C, Pereira AM, Almeida R, Ferreira-Magalhaes M, Couto M, Araujo L, Pereira M, Correia MA, Loureiro CC, Catarata MJ, Maia Santos L, Pereira J, Ramos B, Lopes C, Mendes A, Cidrais Rodrigues JC, Oliveira G, Aguiar AP, Afonso I, Carvalho J, Arrobas A, Coutinho Costa J, Dias J, Todo Bom A, Azevedo J, Ribeiro C, Alves M, Leiria Pinto P, Neuparth N, Palhinha A, Gaspar Marques J, Pinto N, Martins P, Todo Bom F, Alvarenga Santos M, Gomes Costa A, Silva Neto A, Santalha M, Lozoya C, Santos N, Silva D, Vasconcelos MJ, Taborda-Barata L, Carvalhal C, Teixeira MF, Alves RR, Moreira AS, Sofia Pinto C, Morais Silva P, Alves C, Câmara R, Coelho D, Bordalo D, Fernandes RM, Ferreira R, Menezes F, Gomes R, Calix MJ, Marques A, Cardoso J, Emiliano M, Gerardo R, Nunes C, Câmara R, Ferreira JA, Carvalho A, Freitas P, Correia R, Fonseca JA. Patient-physician discordance in assessment of adherence to inhaled controller medication: a cross-sectional analysis of two cohorts. BMJ Open 2019; 9:e031732. [PMID: 31699737 PMCID: PMC6858182 DOI: 10.1136/bmjopen-2019-031732] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE We aimed to compare patient's and physician's ratings of inhaled medication adherence and to identify predictors of patient-physician discordance. DESIGN Baseline data from two prospective multicentre observational studies. SETTING 29 allergy, pulmonology and paediatric secondary care outpatient clinics in Portugal. PARTICIPANTS 395 patients (≥13 years old) with persistent asthma. MEASURES Data on demographics, patient-physician relationship, upper airway control, asthma control, asthma treatment, forced expiratory volume in one second (FEV1) and healthcare use were collected. Patients and physicians independently assessed adherence to inhaled controller medication during the previous week using a 100 mm Visual Analogue Scale (VAS). Discordance was defined as classification in distinct VAS categories (low 0-50; medium 51-80; high 81-100) or as an absolute difference in VAS scores ≥10 mm. Correlation between patients' and physicians' VAS scores/categories was explored. A multinomial logistic regression identified the predictors of physician overestimation and underestimation. RESULTS High inhaler adherence was reported both by patients (median (percentile 25 to percentile 75) 85 (65-95) mm; 53% VAS>80) and by physicians (84 (68-95) mm; 53% VAS>80). Correlation between patient and physician VAS scores was moderate (rs=0.580; p<0.001). Discordance occurred in 56% of cases: in 28% physicians overestimated adherence and in 27% underestimated. Low adherence as assessed by the physician (OR=27.35 (9.85 to 75.95)), FEV1 ≥80% (OR=2.59 (1.08 to 6.20)) and a first appointment (OR=5.63 (1.24 to 25.56)) were predictors of underestimation. An uncontrolled asthma (OR=2.33 (1.25 to 4.34)), uncontrolled upper airway disease (OR=2.86 (1.35 to 6.04)) and prescription of short-acting beta-agonists alone (OR=3.05 (1.15 to 8.08)) were associated with overestimation. Medium adherence as assessed by the physician was significantly associated with higher risk of discordance, both for overestimation and underestimation of adherence (OR=14.50 (6.04 to 34.81); OR=2.21 (1.07 to 4.58)), while having a written action plan decreased the likelihood of discordance (OR=0.25 (0.12 to 0.52); OR=0.41 (0.22 to 0.78)) (R2=44%). CONCLUSION Although both patients and physicians report high inhaler adherence, discordance occurred in half of cases. Implementation of objective adherence measures and effective communication are needed to improve patient-physician agreement.
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Affiliation(s)
- Cristina Jácome
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto (FMUP), Porto, Portugal
| | - Ana Margarida Pereira
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto (FMUP), Porto, Portugal
- Immunoalergology, CUF-Porto Hospital and Institute, Porto, Portugal
| | - Rute Almeida
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto (FMUP), Porto, Portugal
| | - Manuel Ferreira-Magalhaes
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto (FMUP), Porto, Portugal
- Serviço de Pediatria, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Mariana Couto
- Immunoalergology, CUF-Porto Hospital and Institute, Porto, Portugal
| | - Luís Araujo
- Immunoalergology, CUF-Porto Hospital and Institute, Porto, Portugal
| | - Mariana Pereira
- MEDIDA - Medicina, Educação, Investigação, Desenvolvimento e Avaliação, Porto, Portugal
| | | | - Cláudia Chaves Loureiro
- Serviço de Pneumologia A, Hospital Universitário de Coimbra, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Maria Joana Catarata
- Serviço de Pneumologia A, Hospital Universitário de Coimbra, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Lília Maia Santos
- Serviço de Pneumologia A, Hospital Universitário de Coimbra, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - João Pereira
- Serviço de Pneumologia A, Hospital Universitário de Coimbra, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Bárbara Ramos
- Serviço de Pneumologia A, Hospital Universitário de Coimbra, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Cristina Lopes
- Unidade de Imunoalergologia, Unidade Local de Saúde de Matosinhos EPE, Senhora da Hora, Portugal
- Imunologia Básica e Clínica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Ana Mendes
- Serviço de Imunoalergologia, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte EPE, Lisboa, Portugal
| | | | - Georgeta Oliveira
- Serviço de Pediatria, Unidade Local de Saúde de Matosinhos EPE, Senhora da Hora, Portugal
| | - Ana Paula Aguiar
- Serviço de Pediatria, Unidade Local de Saúde de Matosinhos EPE, Senhora da Hora, Portugal
| | - Ivete Afonso
- Serviço de Pediatria, Unidade Local de Saúde de Matosinhos EPE, Senhora da Hora, Portugal
| | - Joana Carvalho
- Serviço de Pediatria, Unidade Local de Saúde de Matosinhos EPE, Senhora da Hora, Portugal
| | - Ana Arrobas
- Serviço de Pneumologia B, Hospital Geral, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - José Coutinho Costa
- Serviço de Pneumologia B, Hospital Geral, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Joana Dias
- Serviço de Pneumologia B, Hospital Geral, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Ana Todo Bom
- Serviço de Imunoalergologia, Hospital Universitário de Coimbra, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - João Azevedo
- Serviço de Imunoalergologia, Hospital Universitário de Coimbra, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Carmelita Ribeiro
- Serviço de Imunoalergologia, Hospital Universitário de Coimbra, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Marta Alves
- Serviço de Imunoalergologia, Hospital Universitário de Coimbra, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
| | - Paula Leiria Pinto
- Serviço de Imunoalergologia, Hospital de Dona Estefânia, Centro Hospitalar de Lisboa Central EPE, Lisboa, Portugal
| | - Nuno Neuparth
- Serviço de Imunoalergologia, Hospital de Dona Estefânia, Centro Hospitalar de Lisboa Central EPE, Lisboa, Portugal
- Pathophysiology, CEDOC, Integrated Pathophysiological Mechanisms Research Group, Nova Medical School, Lisboa, Portugal
| | - Ana Palhinha
- Serviço de Imunoalergologia, Hospital de Dona Estefânia, Centro Hospitalar de Lisboa Central EPE, Lisboa, Portugal
| | - João Gaspar Marques
- Serviço de Imunoalergologia, Hospital de Dona Estefânia, Centro Hospitalar de Lisboa Central EPE, Lisboa, Portugal
| | - Nicole Pinto
- Serviço de Imunoalergologia, Hospital de Dona Estefânia, Centro Hospitalar de Lisboa Central EPE, Lisboa, Portugal
| | - Pedro Martins
- Serviço de Imunoalergologia, Hospital de Dona Estefânia, Centro Hospitalar de Lisboa Central EPE, Lisboa, Portugal
- Pathophysiology, CEDOC, Integrated Pathophysiological Mechanisms Research Group, Nova Medical School, Lisboa, Portugal
| | - Filipa Todo Bom
- Serviço de Pneumologia, Hospital Beatriz Ângelo, Loures, Portugal
| | | | | | | | - Marta Santalha
- Serviço de Pediatria, Hospital da Senhora da Oliveira, Guimaraes, Portugal
| | - Carlos Lozoya
- Serviço de Imunoalergologia, Hospital Amato Lusitano, Castelo Branco, Portugal
| | - Natacha Santos
- Serviço de Imunoalergologia, Centro Hospitalar do Algarve EPE, Faro, Portugal
| | - Diana Silva
- Serviço de Imunoalergologia, Hospital São João, Porto, Portugal
| | | | - Luís Taborda-Barata
- University of Beira Interior, CICS - Health Sciences Research Centre; NuESA - Environment & Health Study Group, Faculty of Health Sciences, Covilha, Portugal
- Cova da Beira University Hospital Centre, Department of Allergy & Clinical Immunology, Covilhã, Portugal
| | - Célia Carvalhal
- Cova da Beira University Hospital Centre, Department of Allergy & Clinical Immunology, Covilhã, Portugal
| | - Maria Fernanda Teixeira
- Serviço de Pediatria, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Rodrigo Rodrigues Alves
- Unidade de Imunoalergologia, Hospital do Divino Espirito Santo de Ponta Delgada EPE, Ponta Delgada, Portugal
| | - Ana Sofia Moreira
- Unidade de Imunoalergologia, Hospital do Divino Espirito Santo de Ponta Delgada EPE, Ponta Delgada, Portugal
| | - Cláudia Sofia Pinto
- Serviço de Pneumologia, Centro Hospitalar de Trás-os-montes e Alto Douro EPE, Vila Real, Portugal
| | | | - Carlos Alves
- Serviço de Pneumologia, Centro Hospitalar Barreiro Montijo EPE, Barreiro, Portugal
| | - Raquel Câmara
- Serviço de Pneumologia, Centro Hospitalar Barreiro Montijo EPE, Barreiro, Portugal
| | - Didina Coelho
- Serviço de Pneumologia, Centro Hospitalar Barreiro Montijo EPE, Barreiro, Portugal
| | - Diana Bordalo
- Serviço de Pediatria, Centro Hospitalar do Médio Ave EPE, Santo Tirso, Portugal
| | - Ricardo M Fernandes
- Pediatrics, Hospital de Santa Maria, Lisbon, Portugal
- Laboratory of Clinical Pharmacology and Therapeutics, University of Lisbon Medical Faculty, Lisboa, Portugal
| | | | - Fernando Menezes
- Serviço de Pneumologia, Hospital Garcia de Orta EPE, Almada, Portugal
| | - Ricardo Gomes
- Serviço de Pneumologia, Hospital Garcia de Orta EPE, Almada, Portugal
| | - Maria José Calix
- Serviço de Pediatria, Centro Hospitalar Tondela Viseu EPE, Viseu, Portugal
| | - Ana Marques
- Serviço de Pediatria, Centro Hospitalar Tondela Viseu EPE, Viseu, Portugal
| | - João Cardoso
- Pneumology, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
- NOVA Medical School, Lisbon, Portugal
| | | | - Rita Gerardo
- Pneumology, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Carlos Nunes
- Imunoalergologia, Centro de Imunoalergologia do Algarve, Portimão, Portugal
| | - Rita Câmara
- Serviço de Imunoalergologia, Serviço de Saúde da Região Autónoma da Madeira, Funchal, Portugal
| | - José Alberto Ferreira
- Serviço de Imunoalergologia, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Aurora Carvalho
- Serviço de Imunoalergologia, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Paulo Freitas
- Bloco operatório, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Ricardo Correia
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), University of Porto Faculty of Medicine, Porto, Portugal
| | - Joao A Fonseca
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto (FMUP), Porto, Portugal
- Immunoalergology, CUF-Porto Hospital and Institute, Porto, Portugal
- MEDIDA - Medicina, Educação, Investigação, Desenvolvimento e Avaliação, Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), University of Porto Faculty of Medicine, Porto, Portugal
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8
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Hagino H, Narita R, Yokoyama Y, Watanabe M, Tomomitsu M. A multicenter, randomized, rater-blinded, parallel-group, phase 3 study to compare the efficacy, safety, and immunogenicity of biosimilar RGB-10 and reference once-daily teriparatide in patients with osteoporosis. Osteoporos Int 2019; 30:2027-2037. [PMID: 31243480 PMCID: PMC6795613 DOI: 10.1007/s00198-019-05038-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 05/28/2019] [Indexed: 01/16/2023]
Abstract
UNLABELLED The efficacy and safety of RGB-10 and reference teriparatide were evaluated in a randomized 52-week study in 250 patients with osteoporosis at high risk of fracture. RGB-10 was equivalent to reference teriparatide in efficacy and had a comparable safety profile. INTRODUCTION RGB-10 is the first biosimilar teriparatide authorized in the European Union. This multicenter, randomized, rater-blinded, parallel-group phase 3 study evaluated equivalence in efficacy and compared safety between RGB-10 and reference teriparatide in patients with osteoporosis at high risk of fracture for registration in Japan. METHODS Ambulatory postmenopausal women and men (≥ 55 years of age) with osteoporosis at high risk of fracture were randomized 1:1 to receive either RGB-10 or reference teriparatide 20 μg once daily via subcutaneous self-injection for 52 weeks. The primary efficacy endpoint was the percent change from baseline to 52 weeks in lumbar spine (L2-L4) bone mineral density (BMD). Safety outcomes and immunogenicity were also assessed. RESULTS In total, 250 patients (125 in each group) were randomized. The percent change from baseline to 52 weeks in lumbar spine (L2-L4) BMD (mean ± standard deviation) was 8.94% ± 6.19% in the RGB-10 group and 9.65% ± 6.22% in the reference teriparatide group. The estimated between-group difference (95% confidence interval) was - 0.65% (- 2.17% to - 0.87%) within the pre-specified equivalence margin (± 2.8%), which indicates equivalence in efficacy between the two groups. Changes in BMD at lumbar spine (L1-L4), femoral neck, and total hip and serum procollagen type I amino-terminal propeptide were also similar between the groups. Safety profiles, including immunogenicity, were comparable. CONCLUSIONS The therapeutic equivalence of RGB-10 to reference teriparatide was demonstrated. RGB-10 had comparable safety profile to that of reference teriparatide.
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Affiliation(s)
- H Hagino
- School of Health Science, Faculty of Medicine, Tottori University, 86 Nishicho, Yonago City, Tottori, 683-8503, Japan.
| | - R Narita
- Mochida Pharmaceutical Co. Ltd, Tokyo, Japan
| | - Y Yokoyama
- Mochida Pharmaceutical Co. Ltd, Tokyo, Japan
| | - M Watanabe
- Mochida Pharmaceutical Co. Ltd, Tokyo, Japan
| | - M Tomomitsu
- Mochida Pharmaceutical Co. Ltd, Tokyo, Japan
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9
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Tabacco G, Bilezikian JP. Osteoanabolic and dual action drugs. Br J Clin Pharmacol 2019; 85:1084-1094. [PMID: 30218587 DOI: 10.1111/bcp.13766] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/06/2018] [Accepted: 09/07/2018] [Indexed: 01/02/2023] Open
Abstract
Teriparatide (TPTD) and abaloparatide (ABL) are the only osteoanabolic drugs available, at this time, for treatment of osteoporosis. TPTD is a 34-amino acid fragment that is identical in its primary sequence to the 34 amino acids of full-length human parathyroid hormone [hPTH(1-84)]. ABL is identical to parathyroid hormone-related peptide (PTHrP) through the first 22 residues with significantly different amino acids inserted thereafter, between residues 22 and 34. The osteoanabolic actions of PTH are due directly to its effects on cells of the osteoblast lineage and indirectly by stimulating IGF-I synthesis and suppressing sclerostin and associated enhancement of Wnt signalling. Both TPTD and ABL are ligands that bind to and activate the PTH receptor type 1 (PTHR1) receptor but they appear to do so differently: ABL favours the transient, more anabolic configuration of the receptor. Both TPTD and ABL reduce the risk of vertebral fractures and non-vertebral fractures. Both drugs are administered for a maximum of 24 months, and should be followed by an antiresorptive agent to maintain gains in bone mineral density (BMD). Romosozumab, a monoclonal antibody that binds to and inhibits sclerostin, appears to have dual actions by stimulating bone formation and reducing bone resorption. In the pivotal clinical trial, romosozumab, administered as a 210 mg monthly subcutaneous dose, significantly reduced new vertebral fractures and in a subsequent study reduced both vertebral and non-vertebral fractures.
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Affiliation(s)
- Gaia Tabacco
- Division of Endocrinology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY, 10032, USA.,Unit of Endocrinology and Diabetes, Department of Medicine, Campus Bio-Medico University of Rome, Italy
| | - John P Bilezikian
- Division of Endocrinology, Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY, 10032, USA
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10
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Napoli N, Langdahl BL, Ljunggren Ö, Lespessailles E, Kapetanos G, Kocjan T, Nikolic T, Eiken P, Petto H, Moll T, Lindh E, Marin F. Effects of Teriparatide in Patients with Osteoporosis in Clinical Practice: 42-Month Results During and After Discontinuation of Treatment from the European Extended Forsteo® Observational Study (ExFOS). Calcif Tissue Int 2018; 103:359-371. [PMID: 29909449 PMCID: PMC6153867 DOI: 10.1007/s00223-018-0437-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 05/25/2018] [Indexed: 02/05/2023]
Abstract
This study aimed to describe clinical outcomes in patients prescribed teriparatide and followed up for 18 months after stopping the drug in real-life conditions. The Extended Forsteo® Observational Study analysed incident clinical fractures in 6-month intervals using logistic regression with repeated measures. Changes in back pain (visual analogue scale) and health-related quality of life (HRQoL; EQ-5D questionnaire) were analysed using mixed models for repeated measures. Patients were analysed if they had a post-baseline visit, regardless of whether and for how long they took teriparatide. Of 1531 patients analysed (90.7% female, mean age: 70.3 years), 76 (5.0%) never took teriparatide. Median treatment duration was 23.6 months. The adjusted odds of clinical fracture decreased by 47% in the > 12- to 18-month treatment period (p = 0.013) compared with the first 6-month period, with no statistically significant reduction in the > 18- to 24-month interval. The clinical fracture rate remained stable during the 18 months' post-teriparatide, when approximately 98% of patients took osteoporosis medication (51% bisphosphonates). Clinical vertebral fractures were reduced at every time period compared with the first 6 months. Adjusted mean back pain scores decreased and EQ-5D scores increased significantly at each post-baseline observation. In a real-life clinical setting, the risk of clinical fractures declined during 24 months of teriparatide treatment. This reduction was maintained 18 months after stopping teriparatide. In parallel, patients reported significant improvements in back pain and HRQoL. The results should be interpreted in the context of the non-controlled design of this observational study.
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Affiliation(s)
- Nicola Napoli
- Division of Endocrinology and Diabetes, University Campus Bio-Medico, Alvaro del Portillo 21, 00128, Rome, Italy.
| | | | - Östen Ljunggren
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Eric Lespessailles
- University Orléans, Orléans, France
- Regional Hospital of Orléans, Orléans, France
| | | | | | | | - Pia Eiken
- Department of Cardiology, Nephrology and Endocrinology, Hillerød Hospital, Hillerød, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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11
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Sato M, Tsujimoto M, Kajimoto K, Uetake H, Shimoda H, Fujiwara S. Effect of a patient-support program on once-daily teriparatide adherence and persistence in the Japan Fracture Observational Study (JFOS). Arch Osteoporos 2018; 13:74. [PMID: 29978364 PMCID: PMC6310708 DOI: 10.1007/s11657-018-0487-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 06/19/2018] [Indexed: 02/03/2023]
Abstract
UNLABELLED Japanese patients with osteoporosis prescribed once-daily teriparatide for 24 months could enroll in a patient-support program designed to aid adherence and persistence. Patients enrolled in the program had higher adherence and persistence rates than those who did not enroll, highlighting the value of patient-support programs for improving adherence and persistence. OBJECTIVE To assess the effect of a patient-support program on once-daily teriparatide adherence and persistence of patients who did and did not enroll. METHODS In the 24-month Japan Fracture Observational Study, patients with osteoporosis prescribed teriparatide 20 μg/day (N = 1996) could freely enroll in a patient-support program (call center support, monthly calendar, certificates of recognition). Outcome measures were medication adherence (investigator assessed) and persistence (first date of teriparatide use to last date of use or study end). Multivariate logistic models were applied for adherence, and Kaplan-Meier survival curve for persistence. RESULTS Overall, mean ± standard deviation (SD) age was 76.9 ± 7.9 years, and the proportion of female patients was 90.1%. Program enrollment status was 39.6% yes (n = 790), 22.9% no (n = 458), and 37.5% unknown (n = 748). In the analysis sample (1248 patients), adherence (> 75%) to teriparatide was more likely for patients enrolled in the support program (54.2 vs. 48.3%; adjusted odds ratio 1.44 [95% confidence intervals 1.04-2.00], p = 0.030). Good to very good (> 75%) adherence was also associated with smoking (negative association) and previous osteoporosis therapy (marginal positive association). Persistence rates were greater for patients enrolled in the support program than not enrolled (12 months 77.2 vs. 69.6%; 24 months 63.2 vs. 54.8%). CONCLUSIONS Once-daily teriparatide adherence and persistence rates were higher among patients who enrolled in a patient-support program than among those who did not, highlighting the value of patient-support programs for improving adherence and persistence.
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Affiliation(s)
- Masayo Sato
- Medicines Development Unit Japan, Eli Lilly Japan K.K, Kobe, Hyogo, Japan.
| | - Mika Tsujimoto
- Medicines Development Unit Japan, Eli Lilly Japan K.K, Kobe, Hyogo, Japan
| | - Kenta Kajimoto
- Medicines Development Unit Japan, Eli Lilly Japan K.K, Kobe, Hyogo, Japan
| | - Hideyuki Uetake
- Statistical Analysis Department, CDM Division, CMIC Co., Ltd., Tokyo, Japan
| | - Hiroo Shimoda
- Statistical Analysis Department, CDM Division, CMIC Co., Ltd., Tokyo, Japan
| | - Saeko Fujiwara
- Health Management and Promotion Center, Hiroshima Atomic Bomb Casualty Council, Hiroshima, Japan
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12
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Usui T, Funagoshi M, Seto K, Ide K, Tanaka S, Kawakami K. Persistence of and switches from teriparatide treatment among women and men with osteoporosis in the real world: a claims database analysis. Arch Osteoporos 2018; 13:54. [PMID: 29725863 DOI: 10.1007/s11657-018-0466-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 04/18/2018] [Indexed: 02/03/2023]
Abstract
UNLABELLED This study investigated the real-world persistence rate and switches of teriparatide-treated patients using a claims database in Japan. The persistence rate of teriparatide at 12 months was 34.9%, and approximately one-third of the patients were not treated with any osteoporosis drugs after teriparatide. Improvement in persistence and switches are desired. PURPOSE We aimed to elucidate the persistence rates and switches before and after teriparatide treatment in real-world osteoporosis patients based on data from a medical claims database in Japan. METHODS We reviewed the records of patients with diagnoses of osteoporosis who were prescribed teriparatide at least once from January 2005 to June 2017. Patients with a follow-up ≤ 90 days before the first and ≤ 90 days after the last prescription of teriparatide were excluded. Discontinuation was defined as no treatment for > 90 days. We investigated treatment duration, compared characteristics of patients with persistence ≤ 12 and > 12 months, and osteoporotic medications before and after teriparatide by weekly or daily teriparatide. RESULTS Among the 553 patients extracted for the study, 81.9% were women, 45.6% were aged ≥ 65 years, and 67.3% had a fracture. The most common fracture site was the spine (39.2%). The overall persistence rate of teriparatide > 12 months was 34.9% (weekly, 23.5%; daily, 43.1%). The subjects with persistence > 12 months comprised a higher proportion of women and they had a higher prevalence of rib and sternum fractures than those with ≤ 12 months. After teriparatide, 38.2% were switched to active vitamin D3, 35.1% to bisphosphonates, and 13.7% to denosumab allowing duplication. However, 34.0% of the patients were not switched to any subsequent medication for osteoporosis. CONCLUSIONS Persistence rate over 12 months of teriparatide treatment was 34.9% in Japan. Approximately one-third of patients had no subsequent treatment immediately after teriparatide. Monitoring persistence and considering subsequent drugs for osteoporosis are necessary for teriparatide treatment.
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Affiliation(s)
- Tomoko Usui
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Masaru Funagoshi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Kahori Seto
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Kazuki Ide
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.,Center for the Promotion of Interdisciplinary Education and Research, Kyoto University, Kyoto, Japan
| | - Shiro Tanaka
- Clinical Biostatistics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.
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Williams AJ, Jordan F, King G, Lewis AL, Illum L, Masud T, Perkins AC, Pearson RG. In vitro and preclinical assessment of an intranasal spray formulation of parathyroid hormone PTH 1–34 for the treatment of osteoporosis. Int J Pharm 2018; 535:113-119. [DOI: 10.1016/j.ijpharm.2017.10.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 12/31/2022]
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Orimo H, Sato M, Kimura S, Wada K, Chen X, Yoshida S, Crawford B. Understanding the factors associated with initiation and adherence of osteoporosis medication in Japan: An analysis of patient perceptions. Osteoporos Sarcopenia 2017; 3:174-184. [PMID: 30775527 PMCID: PMC6372844 DOI: 10.1016/j.afos.2017.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 09/19/2017] [Accepted: 10/19/2017] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES This study aimed to identify factors associated with initiation and adherence of osteoporosis medication from a patient perspective. METHODS A web-based survey was developed based on health behavior theories. Descriptive analyses were conducted for all survey items. Analyses in a structural equation modeling framework were conducted to identify factors associated with treatment initiation and adherence. RESULTS Five hundred forty-five women completed the questionnaire. A majority were currently receiving medications for osteoporosis (n = 376, 69.0%) and 25.0% of these patients (n = 94) were considered adherent to their treatment. Knowledge was strongly associated with osteoporosis treatment initiation (standard error [SE], 0.58). Greater knowledge of disease was associated with increased likelihood of initiating medication. Medication complexity (SE, 0.49) and perceived susceptibility to fracture and loss of independence (SE, -0.37) were also associated with initiation. Perceived barriers (SE, -0.85) such as inconvenience, lack of efficacy and financial burden were observed to be the greatest obstacle to adherence. The greater the perceived barriers, the less likely patients were to adhere to medication. Patients' perception of self-efficacy (SE, 0.37) also affected adherence. The greater the patient perception of ability to independently manage their medication, the more likely they were to adhere to the medication. CONCLUSIONS Different factors were found to be associated with initiation and adherence of osteoporosis medication. Patient knowledge of their disease and the perception of barriers were found to be the most influential. Empowering patients with the knowledge to better understand their disease and decreasing the perception of barriers through education initiatives may be effective in improving patient outcomes.
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Affiliation(s)
- Hajime Orimo
- Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
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15
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Durden E, Pinto L, Lopez-Gonzalez L, Juneau P, Barron R. Two-year persistence and compliance with osteoporosis therapies among postmenopausal women in a commercially insured population in the United States. Arch Osteoporos 2017; 12:22. [PMID: 28243883 PMCID: PMC5329075 DOI: 10.1007/s11657-017-0316-5] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 02/13/2017] [Indexed: 02/03/2023]
Abstract
This retrospective, observational study assessed 2-year persistence and compliance by treatment, route of administration, and dosing frequency in postmenopausal women initiating a new osteoporosis therapy. Two-year persistence and compliance rates were higher in women receiving injectables compared with oral agents. PURPOSE This study extends previous studies limited to 1-year follow-up by examining persistence with osteoporosis therapies over a 2-year period and compares short- and long-term trends in persistence and compliance among postmenopausal women with commercial or Medicare supplemental insurance in the USA. METHODS This retrospective, observational cohort study enrolled women ≥50 years newly initiating osteoporosis therapy between January 1 and December 31, 2012 (i.e., the index date), with continuous enrollment ≥14 months before and ≥24 months after their index date. Persistence (continuous therapy without a >60-day gap) and compliance with the index therapy were evaluated at 2 years of follow-up. Multivariable logistic regression was used to compare the odds of persistence and compliance across treatment and dosing regimens. RESULTS This study included 43,543 patients with mean (standard deviation) age 65 (10) years. At 2 years of follow-up, persistence and compliance were higher for patients treated with injectable agents (ranging from 34 to 41%, excluding an every-3-month injection) than those treated with oral agents (ranging from 20 to 31%). Additionally, patients initiating oral bisphosphonates (except risedronate once daily), raloxifene (daily), or zoledronic acid (annually) had significantly lower odds of persistence compared with denosumab (every 6 months). CONCLUSIONS Patients initiating injectable therapies had greater persistence and compliance at 2 years than those initiating oral therapies. Patients initiating an every-6-month injection had significantly higher persistence compared with those initiating more frequently dosed (e.g., daily and weekly) oral or injectable agents.
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Affiliation(s)
- Emily Durden
- Life Sciences, Truven Health Analytics, 7700 Old Georgetown Road, Bethesda, MD, 20814, USA.
| | - Lionel Pinto
- Global Health Economics, Amgen Inc., 1 Amgen Center Drive, Thousand Oaks, CA, 91320, USA
| | - Lorena Lopez-Gonzalez
- Custom Data Analytics, Life Sciences, Truven Health Analytics, 7700 Old Georgetown Road, Bethesda, MD, 20814, USA
| | - Paul Juneau
- Statistical Services Group, Truven Health Analytics, 7700 Old Georgetown Road, Bethesda, MD, 20814, USA
| | - Richard Barron
- Global Health Economics, Amgen Inc., 1 Amgen Center Drive, Thousand Oaks, CA, 91320, USA
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Keshishian A, Boytsov N, Burge R, Krohn K, Lombard L, Zhang X, Xie L, Baser O. Examining the Effect of Medication Adherence on Risk of Subsequent Fracture Among Women with a Fragility Fracture in the U.S. Medicare Population. J Manag Care Spec Pharm 2017; 23:1178-1190. [PMID: 29083977 PMCID: PMC10398094 DOI: 10.18553/jmcp.2017.17054] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In the United States, osteoporosis affects approximately 10 million people, of whom 80% are women, and it contributes a significant clinical burden to the community. Poor adherence to osteoporosis medications adds to the overall burden of illness. OBJECTIVE To examine the association of osteoporosis medication adherence and the risk of a subsequent fracture among Medicare-enrolled women with a previous fragility fracture. METHODS This study was a retrospective observational analysis of U.S. administrative claims data among female Medicare beneficiaries who had a nontrauma closed fragility fracture between January 1, 2011, and December 31, 2011. Patients were required to have continuous medical and pharmacy enrollment 12 months pre- and postfracture date. In addition, patients were required to have an osteoporosis medication prescription for a bisphosphonate (alendronate, risedronate, pamidronate, etidronate, zoledronate, and tiludronate), calcitonin, denosumab, raloxifene, or teriparatide during the follow-up period. Adherence was calculated using cumulative medication possession ratio (MPR) from the treatment initiation date in 30-day increments. MPR was stratified into high adherence (MPR ≥ 80%), moderate adherence (50% ≤ MPR > 80%), and low adherence (MPR < 50%). Outcomes included first subsequent fracture after treatment initiation; patients were censored at treatment discontinuation, or end of the 12-month period posttreatment initiation. Covariates included demographics, comorbidities, osteoporosis medications, medications associated with falls, and health care utilization. Cox regression was used to model subsequent fractures with time-dependent cumulative MPR. RESULTS Of the 1,292,248 Medicare enrollees who had a fracture in 2011, a total of 103,852 (8.0%) women aged ≥ 65 years with a fragility fracture were identified. Overall, 27,736 (26.7%) patients were treated with osteoporosis medication within 12 months of the fragility fracture (mean time to treatment initiation was 85.0 ± 84.6 days). Over half of the patients were highly adherent (MPR ≥ 80%) to osteoporosis medications during the follow-up (n = 14,112; 50.9%). Almost a third of the patients had low adherence (MPR < 50%; n = 9,022, 32.5%), followed by patients with moderate adherence (50% ≤ MPR > 80%; n = 4,602, 16.6%). After adjusting for demographics and clinical characteristics, patients with low and moderate adherence to osteoporosis medications were 33% (hazard ratio [HR] = 1.33; 95% CI = 1.17-1.50, P < 0.001) and 19% (HR = 1.19; 95% CI = 1.02-1.38, P = 0.026) more likely to have a subsequent fracture, respectively, compared with patients with high adherence. Low adherence patients had a 32% and 34% increased risk for a hip/pelvis/femur fracture (HR = 1.32; 95% CI = 1.09-1.59, P = 0.005) and a clinical vertebral fracture (HR = 1.34; 95% CI = 1.09-1.63, P = 0.005), respectively, compared with high adherence patients. CONCLUSIONS Medicare-enrolled women with low and moderate adherence to osteoporosis medications had a higher risk of a subsequent fracture compared with high adherence patients. These results highlight the importance of improving osteoporosis medication adherence among women enrolled in Medicare. DISCLOSURES This study was funded by Eli Lilly. Xie, Keshishian, and Baser are employees of STATinMED Research, a paid consultant to Eli Lilly in connection with the study design, data analysis, and development of the manuscript for this study. Boytsov, Burge, Lombard, and Zhang are employees and stock owners of Eli Lilly. At the time of research, Krohn was an employee of Eli Lilly. Study concept and design were contributed by Burge and Lombard, along with the other authors. Xie, Baser, and Keshishian took the lead in data collection, assisted by the other authors. Data interpretation was performed by Krohn and Zhang, with assistance from the other authors. The manuscript was written by Keshishian and Boytsov, along with the other authors, and revised by Boytsov, Keshishian, and Burge, along with the other authors.
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Affiliation(s)
| | | | - Russel Burge
- Eli Lilly, Indianapolis, Indiana, and Winkle College of Pharmacy, University of Cincinnati, Cincinnati, Ohio
| | | | | | | | - Lin Xie
- STATinMED Research, Ann Arbor, Michigan
| | - Onur Baser
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University, and STATinMED Research, New York, New York
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17
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Soen S, Fujiwara S, Takayanagi R, Kajimoto K, Tsujimoto M, Kimura S, Sato M, Krege JH, Enomoto H. Real-world effectiveness of daily teriparatide in Japanese patients with osteoporosis at high risk for fracture: final results from the 24-month Japan Fracture Observational Study (JFOS). Curr Med Res Opin 2017; 33:2049-2056. [PMID: 28699789 DOI: 10.1080/03007995.2017.1354826] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The Japan Fracture Observational Study (JFOS), a prospective observational study, investigated the real-world effectiveness of daily teriparatide to reduce clinical fracture risk in osteoporotic patients. METHODS In routine clinical practice, Japanese patients initiated on teriparatide 20 μg/day by subcutaneous injection were enrolled. The primary end-point was the rate of clinical fractures at 6-month intervals over 24 months. Bone mineral density (BMD), procollagen type 1 aminoterminal propeptide (P1NP), back pain, and health-related quality-of-life (HRQoL) information was collected. RESULTS Of 1,996 patients at baseline, 90.1% were female, and mean age was 76.9 years. Teriparatide persistence at 12 and 24 months was 68.0% and 51.6%, respectively. Compared to the first 6-month treatment interval, the odds ratio of fractures decreased by 56.4% during 6-12 months, 51.6% during 12-18 months, and 58.8% during 18-24 months (all p < .01). After 24 months, BMD increased by 17.2% (lumbar spine) and 7.9% (total hip). After 6 months, P1NP levels increased by 259.3%. A reduction in back pain (100 mm visual analog scale) of 16.1 mm at 3 months was maintained through 24 months. HRQoL (pain, daily living activities, general health) improved by ≥10% at each post-baseline time point. Of 279 (14.6%) patients with ≥1 adverse event (AE), 71 (3.7%) experienced ≥1 drug-related AE (investigator assessed), including nausea (0.7%), dizziness (0.4%), and decreased appetite (0.3%). Osteosarcoma was not reported; there were no new safety signals. CONCLUSIONS JFOS demonstrated effectiveness of teriparatide 20 μg/day to reduce the risk of clinical fractures in Japanese patients in a real-world setting.
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Affiliation(s)
- Satoshi Soen
- a Department of Orthopaedic Surgery and Rheumatology , Kindai University, Nara Hospital , Ikoma city , Japan
| | - Saeko Fujiwara
- b Health Management and Promotion Center, Hiroshima Atomic Bomb Casualty Council , Hiroshima city , Japan
| | - Ryoichi Takayanagi
- c Center for Preventive Medicine, Fukuoka Sanno Hospital , Fukuoka , Japan
- d International University of Health and Welfare , Fukuoka , Japan
| | - Kenta Kajimoto
- e Medicines Development Unit Japan, Eli Lilly Japan K.K. , Kobe , Japan
| | - Mika Tsujimoto
- e Medicines Development Unit Japan, Eli Lilly Japan K.K. , Kobe , Japan
| | - Shuichi Kimura
- e Medicines Development Unit Japan, Eli Lilly Japan K.K. , Kobe , Japan
| | - Masayo Sato
- e Medicines Development Unit Japan, Eli Lilly Japan K.K. , Kobe , Japan
| | - John H Krege
- f Bio-Medicines Core Team, Eli Lilly and Company , Indianapolis , IN , USA
| | - Hiroyuki Enomoto
- e Medicines Development Unit Japan, Eli Lilly Japan K.K. , Kobe , Japan
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O'Hanlon CE, Parthan A, Kruse M, Cartier S, Stollenwerk B, Jiang Y, Caloyeras JP, Crittenden DB, Barron R. A Model for Assessing the Clinical and Economic Benefits of Bone-forming Agents for Reducing Fractures in Postmenopausal Women at High, Near-term Risk of Osteoporotic Fracture. Clin Ther 2017. [PMID: 28629610 DOI: 10.1016/j.clinthera.2017.05.348] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE The goal of this study was to assess and compare the potential clinical and economic value of emerging bone-forming agents using the only currently available agent, teriparatide, as a reference case in patients at high, near-term (imminent, 1- to 2-year) risk of osteoporotic fractures, extending to a lifetime horizon with sequenced antiresorptive agents for maintenance treatment. METHODS Analyses were performed by using a Markov cohort model accounting for time-specific fracture protection effects of bone-forming agents followed by antiresorptive treatment with denosumab. The alternative bone-forming agent profiles were defined by using assumptions regarding the onset and total magnitude of protection against fractures with teriparatide. The model cohort comprised 70-year-old female patients with T scores below -2.5 and a previous vertebral fracture. Outcomes included clinical fractures, direct costs, and quality-adjusted life years. The simulated treatment strategies were compared by calculating their incremental "value" (net monetary benefit). FINDINGS Improvements in the onset and magnitude of fracture protection (vs the teriparatide reference case) produced a net monetary benefit of $17,000,000 per 10,000 treated patients during the (1.5-year) bone-forming agent treatment period and $80,000,000 over a lifetime horizon that included 3.5 years of maintenance treatment with denosumab. IMPLICATIONS Incorporating time-specific fracture effects in the Markov cohort model allowed for estimation of a range of cost savings, quality-adjusted life years gained, and clinical fractures avoided at different levels of fracture protection onset and magnitude. Results provide a first estimate of the potential "value" new bone-forming agents (romosozumab and abaloparatide) may confer relative to teriparatide.
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Affiliation(s)
- Claire E O'Hanlon
- Pardee RAND Graduate School, Santa Monica, California; Amgen, Thousand Oaks, California
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Modi A, Sajjan S, Insinga R, Weaver J, Lewiecki EM, Harris ST. Frequency of discontinuation of injectable osteoporosis therapies in US patients over 2 years. Osteoporos Int 2017; 28:1355-1363. [PMID: 28058444 DOI: 10.1007/s00198-016-3886-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 12/14/2016] [Indexed: 01/09/2023]
Abstract
UNLABELLED Little is known about treatment patterns with injectable osteoporosis therapies. At 12 months, the probability of discontinuation was 69.1% among patients using ibandronate, followed by teriparatide (67.1%), zoledronic acid (59.2%), and denosumab (48.8%). By 24 months, discontinuation was higher for each treatment. The majority of US patients discontinue injectable osteoporosis treatment by the end of the first year following initiation. INTRODUCTION This study was designed to assess the frequency of treatment discontinuation over time among patients who initiate injectable osteoporosis therapies. METHODS This retrospective observational study utilized an administrative claims database to measure discontinuation of injectable osteoporosis therapy, reported at 6-month intervals over 2 years. Eligible patients were aged ≥55 years, had newly initiated injectable osteoporosis therapy between January 2008 and June 2012, and were continuously enrolled in the health plan for ≥1 year prior to and ≥1.5 years after the date the first injectable medication was received (the index date). Follow-up time ranged from 18 to 24 months. Injectable osteoporosis treatments included in the analysis were denosumab, ibandronate, teriparatide, and zoledronic acid. Discontinuation was assessed using Kaplan-Meier survival analysis and was defined at each time point as the percentage of patients who did not receive the dose scheduled for that time point. A 90-day grace period was allowed to accommodate flexibility in the scheduling of post-index re-administrations. Sensitivity analyses assessed discontinuation using grace periods of 60 and 30 days. RESULTS A total of 4756 patients met the inclusion criteria for the study, with 617 utilizing denosumab, 233 ibandronate, 778 teriparatide, and 3128 zoledronic acid. At 12 months, discontinuation was highest among patients using ibandronate (69.1%), followed by teriparatide (67.1%), zoledronic acid (59.2%), and denosumab (48.8%). By 24 months, discontinuation was higher for each treatment: 87.5% for ibandronate, 87.9% for teriparatide, 79.8% for zoledronic acid, and 64.3% for denosumab. CONCLUSIONS The majority of US patients discontinue injectable osteoporosis treatment by the end of the first year following initiation.
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Affiliation(s)
- A Modi
- Center for Observational and Real-World Evidence, Merck & Co., Inc, 600 Corporate Drive, Mailstop: CRB-205, Kenilworth, NJ, USA
| | - S Sajjan
- Center for Observational and Real-World Evidence, Merck & Co., Inc, 600 Corporate Drive, Mailstop: CRB-205, Kenilworth, NJ, USA
| | - R Insinga
- Center for Observational and Real-World Evidence, Merck & Co., Inc, 600 Corporate Drive, Mailstop: CRB-205, Kenilworth, NJ, USA
| | - J Weaver
- Center for Observational and Real-World Evidence, Merck & Co., Inc, 600 Corporate Drive, Mailstop: CRB-205, Kenilworth, NJ, USA.
| | - E M Lewiecki
- University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - S T Harris
- UCSF Medical Center, University of California, San Francisco, CA, USA
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20
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Burge RT, Disch DP, Gelwicks S, Zhang X, Krege JH. Hip and other fragility fracture incidence in real-world teriparatide-treated patients in the United States. Osteoporos Int 2017; 28:799-809. [PMID: 28028555 PMCID: PMC5306167 DOI: 10.1007/s00198-016-3888-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 12/15/2016] [Indexed: 12/23/2022]
Abstract
UNLABELLED This study demonstrates real-world effectiveness of teriparatide in reducing the risk of hip and other fragility fractures. Fracture incidence significantly decreased as adherence and persistence increased for any clinical, vertebral, nonvertebral, and hip fractures among patients who were observed for 2 years after teriparatide initiation. INTRODUCTION Examine the relationship of treatment adherence and persistence to teriparatide with hip and other fractures. METHODS Truven MarketScan Research Databases, 2004 through 2014, provided teriparatide users ≥18 years old with continuous coverage 12 months pre- and 24 months post-teriparatide prescription. Adherence (medication possession ratio, MPR) groups were defined as high (≥0.80), medium (0.50 ≤ MPR < 0.80), and low (<0.50). Persistence, allowing for ≤90-day gaps between prescriptions, was defined as 1-6, 7-12, 13-18, and 19-24 months. Fracture incidence was summarized and compared by using ANOVA and logistic regression models; the effects of adherence were examined with Cox proportional hazard models with time-dependent covariates for teriparatide exposure. RESULTS Among 14,284 teriparatide subjects, mean age was 68.4 years, 89.8% were female, and 29.6% had a fracture in the previous year; these characteristics were similar across MPR and persistence groups. The effects of adherence and persistence to teriparatide were statistically significant (P < .001) for all fracture types except wrist (P ≥ .125). By logistic regression, high vs low adherence was associated with reduced risk for any (OR = 0.67; P < .001); vertebral (OR = 0.64; P < .001); nonvertebral (OR = 0.71; P < .001); and hip fractures (OR = 0.52; P < .001) and longer (19-24 months) vs shorter persistence (1-6 months) was associated with reduced risk for any (OR = 0.63, P < .001); vertebral (OR = 0.56, P < .001); nonvertebral (OR = 0.69, P < .001); and hip fractures (OR = 0.48, P < .001). Cox models revealed a significantly reduced risk between high and low adherence for any (OR = 0.69, P < .001); vertebral (OR = 0.60, P < .001); nonvertebral (OR = 0.77, P < .001); and hip fractures (OR = 0.55, P < .001). CONCLUSION Fracture incidence significantly decreased as persistence and adherence to teriparatide increased.
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Affiliation(s)
- R T Burge
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA.
- University of Cincinnati, Cincinnati, OH, USA.
| | - D P Disch
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
| | - S Gelwicks
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
| | - X Zhang
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
| | - J H Krege
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA
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21
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Caggiari G, Leali PT, Mosele GR, Puddu L, Badessi F, Doria C. Safety and effectiveness of teriparatide vs alendronate in postmenopausal osteoporosis: a prospective non randomized clinical study. ACTA ACUST UNITED AC 2017; 13:200-203. [PMID: 28228782 DOI: 10.11138/ccmbm/2016.13.3.200] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In this work we study the safety and effectiveness of teriparatide and alendronate in patients with postmenopausal osteoporosis at high risk of fracture; it was a double-blinded and it was done by examining the comparisons between teriparatide 20 μg/day and alendronate 10 mg/day. Safety and effectiveness analyses were based on data from 355 woman with a mean age of 68 years. Two groups (A and B) with T-score ≤-2.5 at bone mineral density were analyzed and 3 or more vertebral fractures on radiograph. Group A: was treated with teriparatide 20 μg/day and composed from 182 women, in post-menopausal age, without a history of cancer. Group B: was treated with alendronate 10 mg/day composed from 173 women, postmenopausal age, with previous history of cancer (non-active during the study). Clinical evaluations were on bone turnover markers (alkaline phosphatase, procollagene type 1 N-terminal propeptide, and N-telopeptide cross-links), dual-energy X-ray absorptiometry and health-related quality of life (HrQoL). Safety was assessed by reporting of adverse drug reactions (ADRs). The results of this study imply that teriparatide comparated with alendronate has a favorable safety profile and is effective in the treatment of patients with osteoporosis at high risk of fracture.
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Affiliation(s)
| | | | | | - Leonardo Puddu
- Orthopaedic Department, University of Sassari, Sassari, Italy
| | - Francesca Badessi
- Department of Clinical Endocrinology, University of Sassari, Sassari, Italy
| | - Carlo Doria
- Orthopaedic Department, University of Sassari, Sassari, Italy
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22
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Chan DC, Chang CHC, Lim LC, Brnabic AJM, Tsauo JY, Burge R, Hsiao FY, Jin L, Gürbüz S, Yang RS. Association between teriparatide treatment persistence and adherence, and fracture incidence in Taiwan: analysis using the National Health Insurance Research Database. Osteoporos Int 2016; 27:2855-2865. [PMID: 27172935 PMCID: PMC4981624 DOI: 10.1007/s00198-016-3611-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 04/18/2016] [Indexed: 11/24/2022]
Abstract
UNLABELLED Medication persistence and adherence are critical for osteoporosis outcomes. Using the Taiwan National Health Insurance Research Database, we found that persistence and adherence to teriparatide were low in Taiwanese patients with osteoporosis and that greater persistence and adherence were associated with a lower incidence of hip and other nonvertebral fractures. INTRODUCTION The purpose of this study was to determine the persistence and adherence to teriparatide treatment in Taiwanese patients with osteoporosis, and to examine the association between persistence and adherence to teriparatide with fracture risks. METHODS Medical and pharmacy claims for 4,692 patients with vertebral or hip fractures and teriparatide prescriptions between 2005 and 2008 were identified (Taiwan National Health Insurance Research Database). Persistence was the time from the start of treatment to the first 90-day gap between two teriparatide prescriptions. Adherence was the number of teriparatide pens (each pen is used over 1 month) prescribed over 24 months. Association of persistence and adherence to teriparatide with fracture incidence was assessed using adjusted Cox proportional hazards models. RESULTS The proportion of patients persisting with teriparatide for >6 months and >12 months was 44.6 and 24.9 %, respectively. Over 24 months, 53.6 % of patients were adherent for >6 months and 33.9 % were adherent for >12 months. Patients persisting for >12 months had a significantly lower incidence of hip (adjusted hazard ratio [HR], 0.61 [95 % confidence interval (CI), 0.40-0.93], P = 0.0229) and nonvertebral fracture (HR, 0.79 [95 % CI, 0.63-0.99], P = 0.0462) compared with those who persisted for ≤12 months. Patients adherent for >12 months had a lower incidence of hip (HR, 0.66 [95 % CI, 0.46-0.96], P = 0.0286) and nonvertebral fracture (HR, 0.81 [95 % CI, 0.66-0.99], P = 0.0377) compared with those adherent for ≤12 months. CONCLUSIONS Persistence and adherence to teriparatide over 24 months were low in Taiwanese patients with osteoporosis; greater adherence and persistence were associated with a lower incidence of nonvertebral fractures.
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Affiliation(s)
- D-C Chan
- Superintendent Office, Chu-Tung Branch, National Taiwan University Hospital, Hsinchu County, Taiwan
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | | | - L-C Lim
- Department of Geriatrics and Gerontology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Orthopaedics, National Taiwan University Hospital, No. 7. Chung-Shan S. Rd., Taipei, 100, Taiwan
| | - A J M Brnabic
- Real World Analytics, Eli Lilly Australia Pty Ltd, Sydney, Australia
| | - J-Y Tsauo
- School and Graduate Institute of Physical Therapy, National Taiwan University, Taipei, Taiwan
| | - R Burge
- Global Health Outcomes, Eli Lilly and Company, Indianapolis, IN, USA
| | - F-Y Hsiao
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - L Jin
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - S Gürbüz
- Eli Lilly and Company, Indianapolis, IN, USA
| | - R-S Yang
- Department of Orthopaedics, National Taiwan University Hospital, No. 7. Chung-Shan S. Rd., Taipei, 100, Taiwan.
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23
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Langdahl BL, Ljunggren Ö, Benhamou CL, Marin F, Kapetanos G, Kocjan T, Lespessailles E, Napoli N, Nikolic T, Petto H, Moll T, Lindh E. Fracture Rate, Quality of Life and Back Pain in Patients with Osteoporosis Treated with Teriparatide: 24-Month Results from the Extended Forsteo Observational Study (ExFOS). Calcif Tissue Int 2016; 99:259-71. [PMID: 27137783 PMCID: PMC4960288 DOI: 10.1007/s00223-016-0143-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 04/12/2016] [Indexed: 11/16/2022]
Abstract
We describe the pre-planned interim analysis of fracture outcomes, health-related quality of life (HRQoL) and back pain in patients with severe osteoporosis treated with teriparatide for up to 24 months in the Extended Forsteo (Forsteo(®) is a registered trade name of Eli Lilly and Company) Observational Study (ExFOS), a prospective, multinational, observational study. Data on incident clinical fractures, HRQoL (EQ-5D questionnaire) and back pain [100 mm visual analogue scale (VAS)] were collected. The number of patients with fractures was summarised in 6-month intervals and fracture rate over each 6-month period was assessed using logistic regression for repeated measures. Changes from baseline in EQ-5D and back pain VAS were analysed using mixed models for repeated measures. Of 1454 patients in the active treatment cohort, 90.6 % were female and 14.4 % were taking glucocorticoids. During teriparatide treatment (median duration 23.7 months), 103 patients (7.1 %) sustained a total of 122 incident clinical fractures (21 % vertebral, 79 % non-vertebral). A 49 % decrease in the odds of fractures and a 75 % decrease in the odds of clinical vertebral fractures were observed in the >18- to 24-month period versus the first 6-month period (both p < 0.05). EQ-5D scores and back pain VAS scores were significantly improved from baseline at each post-baseline observation during teriparatide treatment. In conclusion, patients with severe osteoporosis showed a significant reduction in the incident fracture rate during 24 months of teriparatide treatment in routine clinical practice, accompanied by a significant improvement in HRQoL and reduction in back pain. Results should be interpreted in the context of the non-controlled design of this observational study.
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Affiliation(s)
- Bente L Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Tage Hansens Gade 2, 8000, Aarhus, Denmark.
| | - Östen Ljunggren
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | | | | | | | - Eric Lespessailles
- Orléans Hospital, Orléans, France
- EA-4708-I3MTO, University of Orléans, Orléans, France
| | | | | | | | - Thomas Moll
- Eli Lilly and Company, Windlesham, Surrey, UK
| | - Erik Lindh
- Eli Lilly and Company, Windlesham, Surrey, UK
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24
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Lindsay R, Krege JH, Marin F, Jin L, Stepan JJ. Teriparatide for osteoporosis: importance of the full course. Osteoporos Int 2016; 27:2395-410. [PMID: 26902094 PMCID: PMC4947115 DOI: 10.1007/s00198-016-3534-6] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 02/09/2016] [Indexed: 11/01/2022]
Abstract
Teriparatide (TPTD) is the only currently available therapeutic agent that increases the formation of new bone tissue and can provide some remediation of the architectural defects in the osteoporotic skeleton. The use of teriparatide clinically is limited to 24 months. We review clinical findings during daily teriparatide treatment over time. Teriparatide appears to increase bone formation more than bone resorption as determined biochemically and histologically. Teriparatide exerts its positive effects on bone formation in two distinct fashions. The first is direct stimulation of bone formation that occurs within active remodeling sites (remodeling-based bone formation) and on surfaces of bone previously inactive (modeling-based bone formation). The second is an increase in the initiation of new remodeling sites. Both processes contribute to the final increase in bone density observed by non-invasive tools such as DXA. Remodeling is the repair process by which skeletal tissue is maintained in a young healthy state, and when stimulated by TPTD is associated with a positive bone balance within each remodeling cavity. It seems likely therefore that this component will contribute to the anti-fracture efficacy of TPTD. Teriparatide reduces the risk of fracture, and this effect appears to increase with longer duration of therapy. The use of novel treatment regimens, including shorter courses, should be held in abeyance until controlled clinical trials are completed to define the relative fracture benefits of such approaches in comparison to the 24-month daily use of the agent. Summary In patients with osteoporosis at high risk for fracture, the full continuous 24-month course with teriparatide results in improved skeletal health and outcomes than shorter time periods.
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Affiliation(s)
- R Lindsay
- Helen Hayes Hospital, West Haverstraw, NY, USA
| | - J H Krege
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA.
| | - F Marin
- Lilly Research Centre, Eli Lilly and Company, Windlesham, Surrey, UK
| | - L Jin
- Lilly Research Laboratories, Eli Lilly and Company, Indianapolis, IN, USA
| | - J J Stepan
- Institute of Rheumatology, Faculty of Medicine 1, Charles University, Prague, Czech Republic
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25
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Nishikawa A, Ishida T, Taketsuna M, Yoshiki F, Enomoto H. Safety and effectiveness of daily teriparatide in a prospective observational study in patients with osteoporosis at high risk of fracture in Japan: final report. Clin Interv Aging 2016; 11:913-25. [PMID: 27462147 PMCID: PMC4939987 DOI: 10.2147/cia.s107285] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
This postmarketing surveillance study assessed the safety and effectiveness of teriparatide in patients with osteoporosis at high risk of fracture in Japan. The patients received teriparatide 20 μg daily by subcutaneous injection, for a maximum of 24 months. Safety and effectiveness analyses were based on data from 1,847 patients who were predominantly female (92.6%) with a mean age of 75.4 years. A total of 157 adverse drug reactions (ADRs) were reported in 140 (7.58%) patients; the most common ADRs were hyperuricemia, nausea, and dizziness. Only six (0.32%) patients reported serious ADRs, the most common being nausea (two patients; 0.1%). Persistence with teriparatide treatment was 60.8% and 39.1% at 18 and 24 months, respectively. There were significant increases in biomarkers for bone formation (procollagen type I N-terminal propeptide and bone-specific alkaline phosphatase) and bone resorption (collagen type I cross-linked C telopeptide and tartrate-resistant acid phosphatase 5b) throughout the study. These were accompanied by significant increases in bone mineral density and low incidences of new vertebral and nonvertebral fractures. Patient-reported measurements for health-related quality of life revealed significant improvements from baseline in back pain and overall health-related quality of life (Short Form-8™ health survey). The results of this 24-month postmarketing surveillance study imply that teriparatide has a favorable safety profile and is effective in the treatment of patients with osteoporosis at high risk of fracture in Japan. Teriparatide may also be a useful treatment for osteoporosis in other societies with aging populations.
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Affiliation(s)
| | - Takehiro Ishida
- Clinical Development Operations and Innovations, Medicine Development Unit Japan
| | | | - Fumito Yoshiki
- Medical Sciences, Medicines Development Unit Japan, Eli Lilly Japan K.K., Kobe, Japan
| | - Hiroyuki Enomoto
- Medical Sciences, Medicines Development Unit Japan, Eli Lilly Japan K.K., Kobe, Japan
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26
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Krege JH, Burge RT, Marin F. Teriparatide fracture effectiveness in the real world. Osteoporos Int 2015; 26:2217-8. [PMID: 25906242 DOI: 10.1007/s00198-015-3140-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 04/09/2015] [Indexed: 11/27/2022]
Affiliation(s)
- J H Krege
- Eli Lilly and Company, Lilly Corporate Center, Drop Code 1546, Indianapolis, IN, 46285, USA,
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27
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Aloumanis K, Kapetanos G, Bartzis N, Drossinos V. Teriparatide use during an economic crisis: baseline data from the Greek cohort of the Extended Forsteo Observational Study (ExFOS). BMC Musculoskelet Disord 2015; 16:136. [PMID: 26044820 PMCID: PMC4457272 DOI: 10.1186/s12891-015-0600-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 05/27/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Extended Forsteo Observational Study (ExFOS) is a multinational, non-interventional, prospective, observational study that aims to provide real-life data on patients with osteoporosis treated with teriparatide for up to 24 months. It includes the new indications of osteoporosis in men and glucocorticoid-induced osteoporosis (GIOP). We describe the Greek subpopulation enrolled in this study and compare it with a similar cohort from the previous European Forsteo Observational Study (EFOS). METHODS Baseline data were collected from the Greek cohort of ExFOS. Data included demographic characteristics, medical and osteoporosis history, disease status, prior use of medications, back pain and quality of life. RESULTS Baseline data for 439 patients, enrolled at 31 sites, indicated the majority of patients were females (92.3%), elderly [mean (standard deviation; SD) age 70.1 (9.8) years] and slightly overweight [mean (SD) body mass index 26.7 (4.3) kg/m(2)], with very low bone mineral density (mean T-score <-3 in lumbar spine or total hip) and at least one previous fracture (55.1% of patients). Of the 439 patients, 19.8% were osteoporosis treatment naïve, 88.4% had experienced back pain during the previous 12 months, 68.1% had experienced back pain at least fairly often during the previous month and 50.9% reported moderate to severe limitation of activities due to back pain, with a mean (SD) of 4.2 (7.7) days spent in bed because of back pain during the previous month. Most baseline characteristics were numerically similar between the female ExFOS and EFOS cohorts; however, the rate of enrolment was faster in ExFOS (by approximately 45%) and a history of fracture was recorded in 53.8% of female patients in ExFOS versus 74.5% in EFOS. CONCLUSIONS Greek patients prescribed teriparatide in ExFOS had severe osteoporosis with a high risk of fractures and back pain. Female patients shared similarities with EFOS counterparts, reflecting a constant prescribing profile for use of teriparatide, although a noticeable difference in fracture history between the two study cohorts may indicate a change towards prescribing in less severely affected patients. The economic crisis in Greece did not appear to affect patient enrolment. Data are interpreted in the context of an observational setting.
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Affiliation(s)
- Kyriakos Aloumanis
- Department of Medical Research, Pharmaserve Lilly SACI, Arkadias 1 and Megaloupoleos str, 14564 Kifissia, Athens, Greece.
| | - George Kapetanos
- 3rd Orthopedics University Clinic, Papageorgiou General Hospital, Thessaloniki, Greece.
| | - Nikolaos Bartzis
- Department of Medical Research, Pharmaserve Lilly SACI, Arkadias 1 and Megaloupoleos str, 14564 Kifissia, Athens, Greece.
| | - Vangelis Drossinos
- Department of Medical Research, Pharmaserve Lilly SACI, Arkadias 1 and Megaloupoleos str, 14564 Kifissia, Athens, Greece.
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28
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Bonafede MM, Shi N, Bower AG, Barron RL, Grauer A, Chandler DB. Teriparatide treatment patterns in osteoporosis and subsequent fracture events: a US claims analysis. Osteoporos Int 2015; 26:1203-12. [PMID: 25567774 PMCID: PMC4331607 DOI: 10.1007/s00198-014-2971-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 11/16/2014] [Indexed: 01/30/2023]
Abstract
UNLABELLED The objective of this study was to describe the risk of fragility-related fractures in the 2 years following teriparatide initiation. In an administrative claims analysis of over 11,407 patients, approximately one in eight patients had a new or recurrent fragility-related fracture in the 2 years following teriparatide initiation. INTRODUCTION The objective of this study was to describe the risk of fragility-related fractures in the 2 years following the initiation of teriparatide in a real-world setting. METHODS This retrospective study used data from the 2002 to 2011 MarketScan® Commercial and Medicare Supplemental Databases to identify patients 50 years and older with a diagnosis of osteoporosis (ICD-9-CM code 733.0x) who were initiating teriparatide. Patients were required to have continuous medical and pharmacy benefit coverage for the 12 months prior to and 24 months following teriparatide initiation (index event). Teriparatide treatment patterns (persistence and adherence) were described, as was the use of antiresorptive therapy. The primary study outcome was the presence of a new or recurring fragility fracture following the initiation of teriparatide. RESULTS A total of 11,407 patients met the study criteria (mean age = 69.5, standard deviation = 10.6 years; 92.0% female). One in four (25.6%) patients had fragility fracture claims in the year prior to teriparatide initiation, of which 64.0% were on existing antiresorptive therapy. Overall, 13.4% (n = 1527) of patients had a new or recurrent fracture during the 2-year follow-up period. Forty-eight percent of patients on teriparatide treatment were considered persistent; fragility fractures were more common among patients nonpersistent with teriparatide (15.2%) than among those persistent with teriparatide (11.4%). A higher fracture rate (35.7%) was observed in the cohort with previous fragility fracture then those without pre-index fractures (24%). CONCLUSION More than 13.4% of patients had new or recurrent fragility-related fractures during the 2 years following the initiation of teriparatide; these fractures were more in common in patients with pre-existing fractures and the patients who were nonpersistent with teriparatide.
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Affiliation(s)
- M M Bonafede
- Life Sciences, Truven Health Analytics, 150 Cambridge Park Dr., Cambridge, MA, 02140, USA,
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Chen JF, Yang KH, Zhang ZL, Chang HC, Chen Y, Sowa H, Gürbüz S. A systematic review on the use of daily subcutaneous administration of teriparatide for treatment of patients with osteoporosis at high risk for fracture in Asia. Osteoporos Int 2015; 26:11-28. [PMID: 25138261 DOI: 10.1007/s00198-014-2838-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 07/31/2014] [Indexed: 12/15/2022]
Abstract
This systematic review aimed to examine the evidence for teriparatide in Asia for osteoporosis with a high fracture risk and for exploratory (unapproved) bone-related indications. MEDLINE (1946+), EMBASE (1966+), and ClinicalTrials.gov (2008+) were searched (16 August 2013); all studies of daily subcutaneous teriparatide 20 μg for bone-related conditions from China, Hong Kong, Japan, Republic of Korea, Philippines, Singapore, and Taiwan were included. Evidence on efficacy/safety was retrieved primarily from randomized controlled trials (10 publications) of postmenopausal women from Japan and China. In these studies, teriparatide was well tolerated; subjects had significantly greater increases in lumbar spine bone mineral density (BMD) from baseline compared with placebo, antiresorptive agents, or elcatonin/calcitonin; bone turnover markers increased from baseline and were sustained at elevated levels during teriparatide treatment. Few studies reported fracture risk, pain, or quality of life; one study showed a lower incidence of new-onset vertebral fracture with teriparatide versus antiresorptive agents. Nonrandomized studies (nine publications, one unpublished trial) conducted mainly in Taiwan, Japan, and the Republic of Korea provided supporting data for efficacy. The exploratory (unapproved) use of teriparatide (17 publications) for fracture healing and osteonecrosis of the jaw was described primarily in case reports. The clinical effectiveness of teriparatide for treatment of postmenopausal women with osteoporosis who are at high risk of fracture in Asia is focused primarily on improvements in BMD and tolerability. Recommended additional studies may include assessment of fracture risk and the effect of teriparatide on pain, quality of life, and mortality in Asia.
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Affiliation(s)
- J F Chen
- Department of Endocrinology and Metabolism, Chang Gung Memorial Hospital, No. 123, Dapi Rd, Niaosong District, Kaohsiung City, 83301, Taiwan
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Boytsov N, Zhang X, Sugihara T, Taylor K, Swindle R. Osteoporotic fractures and associated hospitalizations among patients treated with teriparatide compared to a matched cohort of patients not treated with teriparatide. Curr Med Res Opin 2015; 31:1665-75. [PMID: 26121328 DOI: 10.1185/03007995.2015.1066765] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare fractures and fracture-related resource utilization (RU) among patients with a recent fracture and treated with teriparatide (TPTD) to a matched cohort of patients not treated with TPTD (non-TPTD). RESEARCH DESIGN AND METHODS Women aged 50 years or older initiating TPTD (N = 5314; index date between 1 January 2007 and 31 December 2012) were identified in an insurance claims database. Patients with fragility fracture (hip, pelvis, clavicle, humerus, wrist, leg or spine) during the 12 months prior to the index date (N = 1164) were selected to control for unmeasured confounding due to absence of bone mineral density test levels. TPTD patients were matched to the non-TPTD cohort using propensity score and exact matching (N = 912). Relative risk (RR) of fracture and fracture-related RU were estimated by Cox proportional hazard modeling, adjusted for potential fracture risk factors. RESULTS Fractures were observed in 4.6%, 8.6%, 10.3%, and 11.3% of TPTD patients and in 9.2%, 15.2%, 19.2% and 21.7% of non-TPTD patients over 6, 12, 18, and 24 months, respectively. The adjusted RR reduction in TPTD was 36% (RR = 0.64, 95% CI: 0.44-0.94) during 6 months, 27% (RR = 0.73, 95% CI: 0.54-0.97) during 12 months, 28% (RR = 0.72, 95% CI: 0.55-0.93) during 18 months, and 28% (RR = 0.72, 95% CI: 0.56-0.92) during 24 months versus matched non-TPTD patients. Fracture-related RU followed a similar trend to that observed for fracture risk. CONCLUSIONS This real-world study found TPTD to be more effective in reducing risk of fragility fractures as early as 6 months with continuous treatment benefit up to 24 months compared to a matched non-TPTD cohort. TPTD patients experienced lower rates of fracture-related RU than non-TPTD patients. Key study limitations include the inability to confirm reported diagnostic and procedural codes and the absence of uninsured and individually insured patients in the claims database.
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Affiliation(s)
| | - Xiang Zhang
- a a Eli Lilly and Company , Indianapolis , IN , USA
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Kyvernitakis I, Kostev K, Kurth A, Albert US, Hadji P. Differences in persistency with teriparatide in patients with osteoporosis according to gender and health care provider. Osteoporos Int 2014; 25:2721-8. [PMID: 25011986 DOI: 10.1007/s00198-014-2810-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 07/02/2014] [Indexed: 11/26/2022]
Abstract
UNLABELLED This analysis investigated the persistence of teriparatide for treatment of osteoporosis in 829 patients according to gender and health care provider treated with teriparatide. This study showed that female patients were less persistent than males and those patients treated in the practices of orthopedic surgeons were more treatment persistent than patients treated in general practitioner (GP) practices. INTRODUCTION The optimal persistency of teriparatide (TPTD) is of the upmost importance to ensure fracture risk reduction and pain relief. Data reporting on gender-specific or health care provider-dependent differences on health care provider-dependent persistence is currently lacking. METHODS We analyzed a large dataset extracted from the Disease Analyzer database (IMS Health, Germany). Out of a dataset of 15 million patients, we identified patients with osteoporosis who received first-time teriparatide prescriptions from January 2005 to December 2012. RESULTS All 829 patients (677 females and 152 males) were included in the study. The patients were treated by 214 general practitioners (GPs) and 143 orthopedic surgeons. After 18 months of follow-up, 39.5 % of the female and 34 % of the male patients discontinued their treatment (p = 0.0308). We found a significant difference in the discontinuation rate of patients treated by orthopedic surgeons (35.0 %) compared to patients treated by GPs (44.2 %) (p = 0.0445). Additionally, at the end of the 18 months of follow up, 39.4 % of female and 47.8 % of male patients were still on treatment. We found a highly significant decreased risk for treatment discontinuation in patients with fractures prior to treatment initiation compared to those without such fractures (hazard ratio (HR) 0.77; 95 % confidence interval (CI) 0.66-0.90). There was a significantly increased risk of treatment discontinuation for female patients (HR 1.38; 95 % CI 1.10-1.74) compared to male patients. CONCLUSIONS In conclusion, female patients presented higher discontinuation rates of TPTD compared to males. Patients treated in the practices of orthopedic surgeons were more persistent than patients treated in GP practices. TPTD persistence in patients with osteoporosis is higher than with antiresorptives but is still suboptimal and needs to be improved to ensure fracture risk reductions comparable to randomized controlled trial (RCT) results.
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Affiliation(s)
- I Kyvernitakis
- Department of Endocrinology, Reproductive Medicine and Osteoporosis, Philipps-University of Marburg, Baldingerstr. 1, 35043, Marburg, Germany,
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Yamamoto T, Taketsuna M, Guo X, Sato M, Sowa H. The safety and effectiveness profile of daily teriparatide in a prospective observational study in Japanese patients with osteoporosis at high risk for fracture: interim report. J Bone Miner Metab 2014; 32:699-708. [PMID: 24368586 DOI: 10.1007/s00774-013-0546-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 11/07/2013] [Indexed: 11/26/2022]
Abstract
This postmarketing surveillance study assessed the safety and effectiveness of daily teriparatide treatment in patients with osteoporosis in a Japanese clinical setting. In this prospective, multicenter, observational study, patients with osteoporosis at high risk for fracture received subcutaneous injections of teriparatide (20 μg/day) for a maximum of 24 months. For this interim report, data from 1,671 patients were eligible for analysis at the cutoff date. The mean age was 75.3 years; 93% of patients (1,552/1,671 patients) were women. There were 117 adverse drug reactions (ADRs) reported in 101 of 1,671 patients (6.04%); the most common reported ADRs were nausea, dizziness, headache, and palpitations. No clinically significant safety issues were identified, although 5 serious ADRs were reported in 4/1,671 (0.24 %) patients. At 12 months, 71.9% of patients remained on teriparatide treatment. From 1 month, there were rapid increases in the biomarkers of bone formation P1NP and, to a lesser extent, BAP. In contrast, increases in the biomarkers of bone resorption, serum NTX, urinary NTX, and TRACP5b, were smaller. After 12 months of treatment, there was an increase in bone mineral density at the lumbar spine, femoral neck, and total hip, and a decrease in the Visual Analog Scale score for back pain. The incidence of new vertebral and nonvertebral fractures was 1.21% and 3.18%, respectively. In conclusion, the favorable safety profile and effectiveness of teriparatide observed in this population of Japanese patients with osteoporosis were accompanied by relatively high persistence with treatment, which is a key factor in the success of osteoporosis treatment.
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Affiliation(s)
- Takanori Yamamoto
- Medical Science, Lilly Research Laboratories Development Center of Excellence Japan, Eli Lilly Japan K.K., Sannomiya Plaza Bldg, 7-1-5 Isogamidori, Chuo-ku, Kobe, Hyogo, 651-0086, Japan,
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Zhao Y, Johnston SS, Smith DM, McMorrow D, Krege J, Krohn K. Association between teriparatide adherence and healthcare utilization and costs among hip fracture patients in the United States. Bone 2014; 60:221-6. [PMID: 24361596 DOI: 10.1016/j.bone.2013.12.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 12/02/2013] [Accepted: 12/11/2013] [Indexed: 01/23/2023]
Abstract
PURPOSE This study examined the association between teriparatide (TPTD) adherence, and healthcare utilization and costs among hip fracture (HFx) patients. METHODS Individuals aged 50years and older with an HFx between 1/1/2002-12/31/2010 were identified from a large US administrative claims database. The first HFx date during this period was designated as the index. Selected patients had at least 6months of pre-index continuous enrollment (baseline) and no baseline TPTD use, cancer, or Paget's disease. Patients initiating TPTD post-index were followed until censoring at switch to bisphosphonates, disenrollment, 36months post-index, or diagnosis of cancer or Paget's disease. Teriparatide adherence was measured as the proportion of days covered (PDC) by TPTD prescriptions, during the follow-up period, to construct three adherence groups: low (PDC≤0.5), medium (0.5<PDC≤0.8), and high (PDC>0.8) adherence. Outcome measures were repeated HFx, number of inpatient admissions, and per-patient-per-month (PPPM) healthcare costs. Multivariable generalized linear models examined the association between the TPTD adherence groups and the outcomes, adjusting for cross-group differences in patient characteristics. RESULTS A total of 824 patients (mean age 75years, 90% female) were included: 30% low, 27% medium, and 44% high adherence. In multivariable analyses, high adherence was significantly (all p<0.05) directly associated with increased PPPM pharmacy costs ($621 low, $1093 medium, and $1572 high), but also with the lowest inpatient ($963 low, $960 medium, and $629 high) and outpatient ($1087 low, $1068 medium, and $776 high) costs, leading to the highest total costs in the medium adherence group but similar costs in the high and low adherence groups ($2599 low, $3163 medium, and $2869 high). The high adherence group also had the lowest number of inpatient admissions. CONCLUSIONS Significantly increased pharmacy costs associated with the high TPTD adherence group were offset by significantly fewer inpatient admissions, fewer repeated HFx, and lower inpatient and outpatient costs.
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Affiliation(s)
- Yang Zhao
- Eli Lilly and Company, 893S. Delaware St., Indianapolis, IN 46285, USA.
| | - Stephen S Johnston
- Truven Health Analytics, 7700 Old Georgetown Rd., Ste 650, Bethesda, MD 20814, USA
| | - David M Smith
- Truven Health Analytics, 7700 Old Georgetown Rd., Ste 650, Bethesda, MD 20814, USA
| | - Donna McMorrow
- Truven Health Analytics, 7700 Old Georgetown Rd., Ste 650, Bethesda, MD 20814, USA
| | - John Krege
- Eli Lilly and Company, 893S. Delaware St., Indianapolis, IN 46285, USA
| | - Kelly Krohn
- Eli Lilly and Company, 893S. Delaware St., Indianapolis, IN 46285, USA
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Nogues X, Luz Rentero M, Rodríguez AL. Use of an educational support program to assist patients receiving injectable osteoporosis treatment: experience with teriparatide. Curr Med Res Opin 2014; 30:287-96. [PMID: 24102317 DOI: 10.1185/03007995.2013.851659] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Low treatment adherence and persistence are important considerations in the management of chronic disorders such as osteoporosis, as they are linked to the reduced effectiveness of drug therapy. As teriparatide (Forsteo, Eli Lilly and Company, Alcobendas, Spain) is administered by subcutaneous injection using a customized delivery device for 24 months to reduce fracture risk in patients with osteoporosis, an educational support program was developed to assist patients with correctly administering the treatment. METHODS All patients in Spain can voluntarily participate in this ongoing program, which consists of up to 22 phone calls, by a qualified and licensed nurse trained in use of the delivery device, that are designed to improve patients' knowledge of, and to provide a reminder as to how to use, the device. Patients are also sent educational material regarding the delivery device and osteoporosis, and regularly receive needles suitable for the device. This study presents persistence data for all 23,069 patients registered in the program and prescribed teriparatide between September 2007 and June 2010. RESULTS Persistence in the program was 90.8% at 3 months, 83.5% at 6 months, 74.8% at 12 months, 68.5% at 18 months, and 64.1% at 24 months. Patient satisfaction with the educational support program was high at all assessment times, and patients generally found the delivery device easy to use. CONCLUSIONS These results show that patients from all provinces in Spain with severe osteoporosis receiving teriparatide and enrolled in an educational support program had high persistence and satisfaction with the program. However, no control group was included in these analyses and it is possible that selection bias occurred. It is suggested that patient-based strategies similar to this could be beneficial for all long-term treatments.
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Affiliation(s)
- Xavier Nogues
- Internal Medicine Department, Hospital del Mar , Barcelona , Spain
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Zhao Y, Johnston SS, Smith DM, McMorrow D, Krohn K, Krege J. Association between teriparatide adherence and healthcare utilization and costs in real-world US kyphoplasty/vertebroplasty patients. Osteoporos Int 2013; 24:2525-33. [PMID: 23529293 DOI: 10.1007/s00198-013-2324-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 02/12/2013] [Indexed: 11/26/2022]
Abstract
UNLABELLED The objective of this study was to examine the association between teriparatide adherence and healthcare utilization and costs in real-world US kyphoplasty/vertebroplasty (KV) patients. Among KV patients newly initiating teriparatide, significantly increased pharmacy costs associated with high teriparatide adherence were offset by significantly lower inpatient utilization and medical costs. INTRODUCTION This study seeks to examine the association between teriparatide adherence and healthcare utilization/costs in real-world US KV patients. METHODS Identified patients from a large US administrative claims database were aged 50+ with KV from 1/1/2002-12/31/2010 (first observed KV = index). Included individuals had 6+ months of pre-index continuous enrollment and no pre-index teriparatide, cancer, or Paget's disease. Follow-up period for patients initiating teriparatide was ≤36 months post-index. Three teriparatide adherence cohorts were constructed using the proportion of days covered (PDC) during the follow-up period: low (PDC ≤ 0.5), medium (PDC >0.5-≤ 0.8), and high (PDC >0.8). Repeated KV admissions, any inpatient admission, number of inpatient admissions, and per-patient-per-month (PPPM) inpatient, outpatient, pharmacy, and total costs were compared between cohorts. The associations between teriparatide adherence and healthcare utilization/costs were examined using multivariable regression models, adjusting for patient demographics and clinical characteristics. RESULTS Included were 1,568 patients (mean age, 75 years; 82% female): 403 (26%) had low adherence, 382 (24%) medium, and 783 (50%) high. After multivariable adjustment, high adherence was significantly associated with the lowest PPPM inpatient (low = $1,287; medium = $1,005; high = $678) and outpatient (low = $1,464; medium = $1,244; high = $1,077) medical costs, but with increased pharmacy costs (low = $752; medium = $1,159; high = $1,616; all P < 0.05), leading to similar total costs (low = $3,344; medium = $3,376; high = $3,351) between cohorts; high adherence was also significantly associated with the lowest odds of repeated KV admission, any inpatient admission, and number of inpatient admissions (all P < 0.05). CONCLUSIONS Among KV patients initiating teriparatide, significantly increased pharmacy costs associated with high teriparatide adherence were offset by significantly lower inpatient utilization and medical costs.
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Affiliation(s)
- Y Zhao
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA.
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Duque G. Osteoporosis in older persons: current pharmacotherapy and future directions. Expert Opin Pharmacother 2013; 14:1949-58. [DOI: 10.1517/14656566.2013.822861] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Treatment persistence and changes in fracture risk, back pain, and quality of life amongst patients treated with teriparatide in routine clinical care in France: results from the European Forsteo Observational Study. Joint Bone Spine 2013; 81:69-75. [PMID: 23796729 DOI: 10.1016/j.jbspin.2013.05.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 05/02/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The European Forsteo Observational Study assessed the clinical fracture incidence, back pain, quality of life (QoL), and treatment persistence amongst post-menopausal women, who were prescribed teriparatide in routine care in eight European countries. We present the results for France, with health-insurance reimbursement criteria channel teriparatide to women with severe disease and limit treatment to 18 months. METHODS A representative sample of women initiating teriparatide in France was followed in routine care for 36 months. We described patients' characteristics at baseline and persistence to teriparatide (Kaplan-Meier analysis), fracture incidence, back pain, and QoL (EQ-5D) at baseline, 18 and 36 months follow-up (last-observation-carried-forward (LOCF) and mixed-models-for-repeated-measures (MMRM). RESULTS One hundred and sixteen rheumatologists included 309 patients, of whom 290 (93.9%) had at least one follow-up visit. Women's mean age (standard deviation) was 74.5 years (7.4) and 296 (95.8%) had greater or equal to two vertebral fractures prior to teriparatide initiation. Clinical fracture incidence, mainly vertebral fractures, decreased around 6 months after teriparatide initiation, and was sustained at 36 months (P=0.013) when most patients were treated by anti-resorptives. Back pain and EQ-5D measures improved significantly at 18 and 36 months (P<0.0001) in the LOCF analyses but did not improve in the EQ-5D VAS measure after covariate adjustment in the MMRM model. Median treatment duration was 17.4 months. CONCLUSION French women initiating teriparatide in routine care had severe osteoporosis and showed good treatment persistence, consistent with France's insurance reimbursement criteria. Improvements in fracture risk and back pain began soon after treatment and was maintained at 36 months follow-up.
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Long-term mesalamine maintenance in ulcerative colitis: which is more important? Adherence or daily dose. Inflamm Bowel Dis 2013; 19:1123-9. [PMID: 23514878 DOI: 10.1097/mib.0b013e318280b1b8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND There are limited data about the long-term follow-up of patients with ulcerative colitis (UC) maintained on high versus low doses of mesalamine. We evaluated the best long-term average daily dose that would keep the disease in remission. METHODS Nationwide ulcerative colitis data were obtained from the Veterans Affairs health care system for the period 2001 to 2011. Those who started mesalamine maintenance during this period were included. Average daily dose and the level of adherence were assessed for the period between the first mesalamine dispense and the date of first flare defined as the first filling of 40 mg/day or more of oral prednisone or any dose of intravenous steroids. Patients with ulcerative colitis maintained on an average daily dose 2.4 to 2.8 g/day (low dose) were compared with 4.4 to 4.8 g/day (high dose). Adherence was assessed using continuous single interval medication availability indicator. RESULTS We included 4452 patients with a median follow-up of 6 years. There was no significant reduction in the risk of flares when comparing high versus low average mesalamine dose among patients with high [hazard ratio = 0.96, P = 0.8)] and medium (hazard ratio = 0.74, P = 0.17) adherence. However, there was a significant reduction in the risk of flares with high dose of mesalamine among patients with low adherence (hazard ratio = 0.28, P = 0.003). CONCLUSIONS Our data show that when starting a patient on mesalamine, there is no difference in the long-term flare risk between low versus high average daily dose as long as the patients have a high to moderate level of adherence.
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Hazel-Fernandez L, Louder AM, Foster SA, Uribe CL, Burge RT. Association of teriparatide adherence and persistence with clinical and economic outcomes in Medicare Part D recipients: a retrospective cohort study. BMC Musculoskelet Disord 2013; 14:4. [PMID: 23281846 PMCID: PMC3599866 DOI: 10.1186/1471-2474-14-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Accepted: 12/27/2012] [Indexed: 11/10/2022] Open
Abstract
Background Improper medication adherence is associated with increased morbidity, healthcare costs, and fracture risk among patients with osteoporosis. The objective of this study was to evaluate the healthcare utilization patterns of Medicare Part D beneficiaries newly initiating teriparatide, and to assess the association of medication adherence and persistence with bone fracture. Methods This retrospective cohort study assessed medical and pharmacy claims of 761 Medicare members initiating teriparatide in 2008 and 2009. Baseline characteristics, healthcare use, and healthcare costs 12 and 24 months after teriparatide initiation, were summarized. Adherence, measured by Proportion of Days Covered (PDC), was categorized as high (PDC ≥ 80%), moderate (50% ≥ PDC < 80%), and low (PDC < 50%). Non-persistence was measured as refill gaps in subsequent claims longer than 60 days plus the days of supply from the previous claim. Multivariate logistic regression evaluated the association of adherence and persistence with fracture rates at 12 months. Results Within 12 months of teriparatide initiation, 21% of the cohort was highly-adherent. Low-adherent or non-persistent patients visited the ER more frequently than did their highly-adherent or persistent counterparts (χ2 = 5.01, p < 0.05 and χ2 = 5.84, p < 0.05), and had significantly lower mean pharmacy costs ($4,361 versus $13,472 and $4,757 versus $13,187, p < 0.0001). Furthermore, non-persistent patients had significantly lower total healthcare costs. The healthcare costs of highly-adherent patients were largely pharmacy-related. Similar patterns were observed in the 222 patients who had fractures at 12 months, among whom 89% of fracture-related costs were pharmacy-related. The regression models demonstrated no significant association of adherence or persistence with 12-month fractures. Six months before initiating teriparatide, 50.7% of the cohort had experienced at least 1 fracture episode. At 12 months, these patients were nearly 3 times more likely to have a fracture (OR = 2.9, 95% C.I. 2.1-4.1 p < 0.0001). Conclusions Adherence to teriparatide therapy was suboptimal. Increased pharmacy costs seemed to drive greater costs among highly-adherent patients, whereas lower adherence correlated to greater ER utilization but not to greater costs. Having a fracture in the 6 months before teriparatide initiation increased fracture risk at follow-up.
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Adherence and persistence with once-daily teriparatide in Japan: a retrospective, prescription database, cohort study. J Osteoporos 2013; 2013:654218. [PMID: 24455412 PMCID: PMC3876673 DOI: 10.1155/2013/654218] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 10/25/2013] [Indexed: 11/17/2022] Open
Abstract
Adherence and persistence with osteoporosis treatments are essential for reducing fracture risk. Once-daily teriparatide is available in Japan for treating osteoporosis in patients with a high risk of fracture. The study objective was to describe real-world adherence and persistence with once-daily teriparatide 20 μg during the first year of treatment for patients who started treatment during the first eight months of availability in Japan. This prescription database study involved patients with an index date (first claim) between October 2010 and May 2011, a preindex period ≥6 months, and a postindex period ≥12 months and who were aged >45 years. Adherence (medication possession ratio (MPR)) and persistence (time from the start of treatment to discontinuation; a 60-day gap in supply) were calculated. A total of 287 patients started treatment during the specified time period; 123 (42.9%) were eligible for inclusion. Overall mean (standard deviation) adherence was 0.702 (0.366), with 61.0% of patients having high adherence (MPR > 0.8). The percentage of patients remaining on treatment was 65.9% at 180 days and 61.0% at 365 days. Our findings suggest that real-world adherence and persistence with once-daily teriparatide in Japan are similar to that with once-daily teriparatide in other countries and with other osteoporosis medications.
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Liu Y, Song CY, Wu SS, Liang QH, Yuan LQ, Liao EY. Novel adipokines and bone metabolism. Int J Endocrinol 2013; 2013:895045. [PMID: 23431296 PMCID: PMC3575660 DOI: 10.1155/2013/895045] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Accepted: 01/02/2013] [Indexed: 01/25/2023] Open
Abstract
Osteoporosis is a serious social issue nowadays. Both the high morbidity and its common complication osteoporotic fracture load a heavy burden on the whole society. The adipose tissue is the biggest endocrinology organ that has a different function on the bone. The adipocytes are differentiated from the same cell lineage with osteoblast, and they can secrete multiple adipokines with various functions on bone remolding. Recently, several novel adipokines have been identified and investigated thoroughly. In this paper, we would like to highlight the complicated relation between the bone metabolism and the novel adipokines, and it may provide us with a new target for prediction and treatment of osteoporosis.
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Affiliation(s)
- Yuan Liu
- Institute of Metabolism and Endocrinology, Second Xiangya Hospital, Central South University, Changsha 410011, Hunan, China
- Geriatric Department, Second Xiangya Hospital, Central South University, Changsha 410011, Hunan, China
| | - Cheng-Yuan Song
- Neurology Department, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China
| | - Shan-Shan Wu
- Institute of Metabolism and Endocrinology, Second Xiangya Hospital, Central South University, Changsha 410011, Hunan, China
| | - Qiu-Hua Liang
- Institute of Metabolism and Endocrinology, Second Xiangya Hospital, Central South University, Changsha 410011, Hunan, China
| | - Ling-Qing Yuan
- Institute of Metabolism and Endocrinology, Second Xiangya Hospital, Central South University, Changsha 410011, Hunan, China
- *Ling-Qing Yuan:
| | - Er-Yuan Liao
- Institute of Metabolism and Endocrinology, Second Xiangya Hospital, Central South University, Changsha 410011, Hunan, China
- *Er-Yuan Liao: and
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Khan N, Abbas AM, Bazzano LA, Koleva YN, Krousel-Wood M. Long-term oral mesalazine adherence and the risk of disease flare in ulcerative colitis: nationwide 10-year retrospective cohort from the veterans affairs healthcare system. Aliment Pharmacol Ther 2012; 36:755-64. [PMID: 22882428 DOI: 10.1111/apt.12013] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 06/21/2012] [Accepted: 07/18/2012] [Indexed: 01/01/2023]
Abstract
BACKGROUND Adherence is a major factor in determining disease activity in ulcerative colitis (UC). There are limited data on long-term nationwide adherence levels among patients with UC. AIM To evaluate the long-term adherence levels to oral mesalazine (mesalamine) in the Veterans Affairs (VA) healthcare system, to determine the impact of non-adherence on the risk of flares, and to evaluate the different pharmacy data-based adherence indicators. METHODS Nationwide data were obtained from the VA for the period 2001-2011. UC patients who started mesalazine maintenance during the inclusion period were included. Level of adherence was assessed using three different indicators: medication possession ratio (MPR), continuous single-interval medication availability (CSA) and continuous multiple-interval medication gaps (CMG). Cox regression modelling was used to predict disease flares and assess the predictive value of each adherence indicator. RESULTS We included 13 062 patients into the analysis with median follow-up time of 6.1 years. Percentage of patients with high adherence was 47%, 43%, 31% as identified by CSA, MPR and CMG respectively. Low adherers had a significant increase in the risk of flares compared with high adherers (Hazard ratio: 2.8, 1.7 and 1.8, P < 0.001 for CSA, MPR and CMG, respectively). Compared with other adherence indicators, CSA offered the best trend in predicting disease flares. CONCLUSIONS Long-term high-adherence level was lower than previously reported. Adherence was a significant factor in predicting disease flares. Pharmacy adherence indicators may be useful to healthcare providers in identifying patients at high risk of exacerbations.
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Affiliation(s)
- N Khan
- Southeast Louisiana Veterans Health Care System, New Orleans, LA, USA.
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