Adherence to and persistence with zoledronic acid treatment for osteoporosis-reasons for early discontinuation

Bisphosphonate alternative regimens for the prevention of osteoporotic fragility fractures: BLAST-OFF, a mixed-methods study

Background

Bisphosphonates are a class of medication commonly used to treat osteoporosis. Alendronate is recommended as the first-line treatment; however, long-term adherence (both treatment compliance and persistence) is poor. Alternative bisphosphonates are available, which can be given intravenously and have been shown to improve long-term adherence. However, the most clinically effective and cost-effective alternative bisphosphonate regimen remains unclear. What is the most cost-effective bisphosphonate in clinical trials may not be the most cost-effective or acceptable to patients in everyday clinical practice.

Objectives

1. Explore patient, clinician and stakeholder views, experiences and preferences of alendronate compared to alternative bisphosphonates. 2. Update and refine the 2016 systematic review and cost-effectiveness analysis of bisphosphonates, and estimate the value of further research into their benefits. 3. Undertake stakeholder/consensus engagement to identify important research questions and further rank research priorities.

Methods

The study was conducted in two stages, stages 1A and 1B in parallel, followed by stage 2: • Stage 1A - we elicited patient and healthcare experiences to understand their preferences of bisphosphonates for the treatment of osteoporosis. This was undertaken by performing a systematic review and framework synthesis of qualitative studies, followed by semistructured qualitative interviews with participants. • Stage 1B - we updated and expanded the existing Health Technology Assessment systematic review and clinical and cost-effectiveness model, incorporating a more comprehensive review of treatment efficacy, safety, side effects, compliance and long-term persistence. • Stage 2 - we identified and ranked further research questions that need to be answered about the effectiveness and acceptability of bisphosphonates.

Results

Patients and healthcare professionals identified a number of challenges in adhering to bisphosphonate medication, balancing the potential for long-term risk reduction against the work involved in adhering to oral alendronate. Intravenous zoledronate treatment was generally more acceptable, with such regimens perceived to be more straightforward to engage in, although a portion of patients taking alendronate were satisfied with their current treatment. Intravenous zoledronate was found to be the most effective, with higher adherence rates compared to the other bisphosphonates, for reducing the risk of fragility fracture. However, oral bisphosphonates are more cost-effective than intravenous zoledronate due to the high cost of zoledronate administration in hospital. The importance of including patients and healthcare professionals when setting research priorities is recognised. Important areas for research were related to patient factors influencing treatment selection and effectiveness, how to optimise long-term care and the cost-effectiveness of delivering zoledronate in an alternative, non-hospital setting.

Conclusions

Intravenous zoledronate treatment was generally more acceptable to patients and found to be the most effective bisphosphonate and with greater adherence; however, the cost-effectiveness relative to oral alendronate is limited by its higher zoledronate hospital administration costs.

Future work

Further research is needed to support people to make decisions influencing treatment selection, effectiveness and optimal long-term care, together with the clinical and cost-effectiveness of intravenous zoledronate administered in a non-hospital (community) setting.

Limitations

Lack of clarity and limitations in the many studies included in the systematic review may have under-interpreted some of the findings relating to effects of bisphosphonates.

Trial registration

This trial is registered as ISRCTN10491361.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127550) and is published in full in Health Technology Assessment; Vol. 28, No. 21. See the NIHR Funding and Awards website for further award information.

Four-year treatment continuation rates of osteoporosis drugs with different dosing intervals throughout Japan

INTRODUCTION

There are approximately 13 million patients with osteoporosis in Japan; however, only 20% of them receive treatment. This study compared the 4-year continuation rates of osteoporosis drugs at different dosing intervals across throughout Japan.

MATERIALS AND METHODS

Receipt data were analyzed to determine the continuation of osteoporosis medication in patients who began treatment at 210 hospitals throughout Japan between October 2016 and September 2017. Continuation rates were compared using Kaplan-Meier curves and log-rank tests.

RESULTS

The 4-year continuation rates of daily, weekly, monthly, semi-annual, and yearly medications nationwide were 8.6%, 16.5%, 13.5%, 31.0%, and 26.0%, respectively. The 4-year continuation rates for semi-annual and yearly drugs were significantly higher than daily, weekly, monthly drugs.

CONCLUSION

Throughout Japan, the 4-year treatment continuation rates of daily, weekly, monthly, semi-annual, and yearly osteoporosis drugs all decreased over time. However, the continuation rates of semi-annual and yearly drugs in the fourth year were significantly higher than those for the other dosing regimens. Therefore, injectable drugs with dosing intervals ≥6 months may improve continuation rates of osteoporosis drugs. Geriatr Gerontol Int 2023; 23: 665-670.

Divergent Patterns of Antifracture Medication Use Following Fracture on Therapy: A Population-Based Cohort Study

CONTEXT

Fracture on therapy should motivate better antifracture medication adherence.

OBJECTIVE

This study aimed to describe osteoporosis medication adherence in women before and following a fracture.

METHODS

This retrospective cohort analysis of antifracture medication possession ratios (MPR) among women in the Manitoba BMD Registry (1996-2013) included menopausal women who started antifracture drug therapy after a dual-energy x-ray absorptiometry (DXA)-BMD assessment with follow-up for 5 years during which a nontraumatic fracture occurred at least 1 year after starting treatment. Linked prescription records determined medication adherence (estimated by MPR) in 1-year intervals. The variable of interest was MPR in the year before and after the year in which the fracture occurred, with subgroup analyses according to duration of treatment pre-fracture. We chose an MPR of ≥ 0.50 to indicate minimum adherence needed for drug efficacy.

RESULTS

There were 585 women with fracture on therapy, 193 (33%) had hip or vertebral fracture. Bisphosphonates accounted for 82.2% of therapies. Median MPR the year prior to fracture was 0.89 (IQR, 0.49-1.0) and 0.69 (IQR, 0.07-0.96) the year following the year of fracture (P < 0.0001). The percentage of women with MPR ≥ 0.5 pre-fracture was 73.8%, dropping to 57.3% post-fracture (P < 0.0001); when restricted to hip/vertebral fracture, results were similar (58.2% to 33.3%; P < 0.002). Among those with pre-fracture MPR < 0.5, only 21.7% achieved a post-fracture MPR ≥ 0.5.

CONCLUSIONS

Although fracture on therapy may motivate sustained/improved adherence, MPR remains low or even declines after fracture in many. This could reflect natural decline in MPR with time but is paradoxical to expectations. Fracture on therapy represents an important opportunity for clinicians to reemphasize treatment adherence.

Long-term persistence with denosumab: real-world data from the Austrian Osteoporosis Clinic (AOC). A retrospective data analysis

In short-term studies, persistence with denosumab has been higher than with other osteoporosis drugs. This study shows that persistence can be maintained in the long-term and is associated with efficacy and safety parameters.

PURPOSE

To assess long-term persistence with denosumab in postmenopausal women with osteoporosis. Secondary purposes were the evaluation of changes in efficacy and tolerance/safety parameters over time.

METHODS

Persistence was determined by number and rate of patients receiving denosumab on time in 6-month intervals (+ / - 8 weeks). The total population was stratified by internal patients (injections and monitoring at the Austrian Osteoporosis Clinic [AOC], 74%) and external patients (injections at the practitioner's office with occasional monitoring at the AOC, 26%). In internal patients, efficacy parameters including bone mineral density (BMD) and the bone marker CTX were assessed at fixed time points and tolerance/safety parameters including side effects (SEs), adverse events (AEs), and serious AEs (SAEs) evaluated.

RESULTS

Of 851 patients, 71% (73% internal and 64% external) were persistent at 7.5 years of follow-up. The mean rate of cumulative persistence in internal patients decreased from 94% at the time of the second dose to 73% at the time of the fifteenth dose. BMD increased and CTX decreased, overall and in pairwise comparisons (all p < .001). AEs and SAEs, but not SEs, were lower in persistent than non-persistent patients.

CONCLUSIONS

This is the first study showing that long-term (> 3 years) real-world persistence with denosumab could be maintained at a high level (> 70%) in most patients. Denosumab was well tolerated and associated with decreased CTX levels and increased BMD.

Prior adherence to statins is a predictor of subsequent adherence and persistence to oral, but not parenteral, osteoporosis medications

INTRODUCTION

Although bisphosphonates are effective for treating osteoporosis, patient adherence is variable. We conducted this study to determine if prior adherence with another medication used to treat chronic asymptomatic conditions predicts adherence with bisphosphonates.

MATERIALS AND METHODS

Retrospective cohort study using linked population-level data for the entire Canadian province of Alberta between April 1, 2009 and March 31, 2017. We examined all new users of an oral or parenteral osteoporosis treatment over the age of 20 who had filled at least one statin prescription in the prior 12 months before the start date of the osteoporosis treatment. Adherence was defined based on medication possession ratio (MPR) and > = 80% was deemed good adherence. Persistence was defined as continuous treatment without an interruption of treatment for more than 56 days.

RESULTS

Of 20,612 new users of oral bisphosphonates and 1538 new users of parenteral treatments, prior good adherence with statins was independently associated with both short term [adjusted Odds Ratio (aOR) 1.34 (95% CI 1.26-1.42) at 1 year] and long term [aOR 1.35 (1.20-1.51) at 5 years] adherence with oral bisphosphonates. However, there was no association between prior statin adherence and adherence [OR 0.94 (0.74, 1.20)] or persistence [(OR 0.96 (0.76, 1.22)] with parenteral osteoporosis therapies. Other factors associated with oral bisphosphonate adherence at 1 year included older age, history of bone mineral density scan, and history of pap smear.

CONCLUSIONS

Prior adherence to statins is a predictor of subsequent short-term and long-term adherence and persistence with oral bisphosphonates but not parenteral osteoporosis therapies.