Discontinuation of bisphosphonates in seniors: a systematic review on health outcomes

Barriers to osteoporosis management and adherence to Clinical Practice Guideline: a comparative study between tertiary East Coast hospitals and a Fracture Liaison Services (FLS)-accredited hospital in Malaysia

This study compares osteoporosis management between tertiary East Coast hospitals and a FLS-accredited hospital in Malaysia. It identifies significant barriers and highlights the superior performance of FLS in areas like timely treatment initiation and treatment monitoring. The insights are crucial for improving osteoporosis management strategies.

INTRODUCTION

Osteoporosis management poses a substantial healthcare challenge, necessitating effective strategies and Clinical Practice Guidelines (CPG) adherence.

METHODS

The study employed a self-administered online questionnaire via Google Forms. Orthopedic clinicians from all study sites were invited to participate via messaging platforms. A total of 135 participants completed the questionnaire and the data was proceeded to statistical analyses.

RESULTS

The study identified significant barriers, including inadequate knowledge of current osteoporosis guidelines and medications (p = 0.014), limited choice of anti-osteoporosis medication (p < 0.001), insufficient post-fracture care staff (p < 0.001), patients' financial constraints due to socioeconomic status (p = 0.027), and lack of doctor-patient time (p = 0.042). FLS demonstrated superior performance in CPG adherence in areas such as clinical diagnosis of osteoporosis without BMD assessment (p = 0.046), timely treatment initiation (p < 0.001), treatment monitoring using BMD (p = 0.004), reassessment treatment after 3-5 years of bisphosphonate therapy (p = 0.034) and considering anabolic agents in very high-risk patients (p = 0.018).

CONCLUSION

The findings highlight an essential opportunity for improvement and emphasize the necessity for robust strategies and strict adherence to Clinical Practice Guidelines (CPG), especially within tertiary East Coast hospitals. The exemplary efficacy demonstrated by the FLS model strongly advocates for its broader integration across multiple hospitals, promising substantial advancements in osteoporotic patient care outcomes throughout Malaysia.

Deprescribing: An umbrella review

This umbrella review examined systematic reviews of deprescribing studies by characteristics of intervention, population, medicine, and setting. Clinical and humanistic outcomes, barriers and facilitators, and tools for deprescribing are presented. The Medline database was used. The search was limited to systematic reviews and meta-analyses published in English up to April 2022. Reviews reporting deprescribing were included, while those where depre-scribing was not planned and supervised by a healthcare professional were excluded. A total of 94 systematic reviews (23 meta--analyses) were included. Most explored clinical or humanistic outcomes (70/94, 74 %); less explored attitudes, facilitators, or barriers to deprescribing (17/94, 18 %); few focused on tools (8/94, 8.5 %). Reviews assessing clinical or humanistic outcomes were divided into two groups: reviews with deprescribing intervention trials (39/70, 56 %; 16 reviewing specific deprescribing interventions and 23 broad medication optimisation interventions), and reviews with medication cessation trials (31/70, 44 %). Deprescribing was feasible and resulted in a reduction of inappropriate medications in reviews with deprescribing intervention trials. Complex broad medication optimisation interventions were shown to reduce hospitalisation, falls, and mortality rates. In reviews of medication cessation trials, a higher frequency of adverse drug withdrawal events underscores the importance of prioritizing patient safety and exercising caution when stopping medicines, particularly in patients with clear and appropriate indications.

Fracture risk after deprescription of bisphosphonates: Application of real-world data in primary care

PURPOSE

To compare the effect of discontinuing bisphosphonate treatment on fracture risk in postmenopausal women at high versus low risk of fracture.

DESIGN

Retrospective, longitudinal and population-based cohort study.

SETTING

Barcelona City Primary Care. Catalan Health Institute.

PARTICIPANTS

All women attended by primary care teams who in January 2014 had received bisphosphonate treatment for at least five years were included and followed for another five years.

INTERVENTION

Patients were classified according to their risk of new fractures, defined as those who had a history of osteoporotic fracture and/or who received treatment with an aromatase inhibitor, and the continuity or deprescription of the bisphosphonate treatment was analyzed over fiver year follow-up.

MAIN MEASUREMENTS

The cumulative incidence of fractures and the incidence density were calculated and analyzed using logistic regression and Cox models.

RESULTS

We included 3680 women. There were no significant differences in fracture risk in high-risk women who discontinued versus continued bisphosphonate treatment (hazard ratio [HR] 1.17, 95% confidence interval [CI] 0.87-1.58 for total osteoporotic fractures). However, discontinuers at low risk had a lower incidence of fracture than continuers. This difference was significant for vertebral fractures (HR 0.64, 95% CI 0.47-0.88) and total fractures (HR 0.77, 95% CI 0.64-0.92).

CONCLUSION

Our results suggest that deprescribing bisphosphonates in women who have already received five years of treatment does not increase fracture risk. In low-risk women, continuing this treatment might could even favor the appearance of new osteoporotic fractures.

Surface-Modified Silica Hydrogels for the Programmable Release of Bisphosphonate Anti-Osteoporosis Drugs: The Case of Etidronate

Bisphosphonate drugs constitute the primary treatment for bone diseases such as Paget's disease and osteoporosis. Despite their effectiveness, they also exhibit severe drawbacks, such as rapid excretion and limited oral bioavailability. High doses are usually administered to counterbalance these drawbacks. Subsequently, side effects are triggered, such as osteonecrosis of the lower jaw and esophageal cancer. Controlled drug release systems may be viable candidates to overcome those issues. Herein, we present novel functionalized silica-based hydrogels loaded with the osteoporosis drug etidronate (1,1-hydroxyethylidene-diphosphonate) used to control the release profile of the drug. Various methodologies were evaluated to control the initial release rate and the final released concentration of the drug. These included the gel density, by systematically increasing the initial concentration of silicate used to prepare the hydrogels, the presence of metal cations (Ca²⁺ and Cu²⁺), and the internal surface functionalization of the gel with silane-based grafting agents (with anionic, cationic, and neutral groups). This study also contributes to our continuous effort to develop new a priori programmable drug-loaded gels for the controlled release of osteoporosis drugs.

Fractured Timelines: Reporting Patterns for Bisphosphonate-Associated Atypical Fractures and Implications for Postmarket Surveillance

Background Case reports of atypical fractures associated with bisphosphonates first appeared in the literature in 2005, with a larger number of reports published in 2007-2009. Objective To describe reporting trends of bisphosphonate-associated atypical fractures relative to increasing awareness across medical and lay communities. Methods Disproportionality analyses were performed to assess odds of reporting atypical fractures associated with oral bisphosphonates using the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database. Reporting odds ratios (RORs) were assessed according to prespecified time periods (pre-awareness [1995-2006], growing-awareness [2007-2009], and post-warning [2010-2021]). Results There were 182 atypical fracture reports (n = 18 bisphosphonate-associated) during the pre-awareness period, 177 (n = 69 bisphosphonate-associated) during growing-awareness, and 6,170 (n = 3,150 bisphosphonate-associated) post-warning. Among reports by health care professionals, RORs for bisphosphonate-associated atypical fractures were 1.76, 13.49, and 12.16 across the three time periods. In comparison, RORs among all reporters (including consumers) increased from 1.50 to 7.95 to 18.93 across those three time periods. The highest proportion of reports during the pre-awareness period was for patients 51 to 65 years of age; however, patients 66 years of age and older comprised the largest proportion of reports in the growing-awareness and post-warning periods. Discussion Reporting patterns for atypical fractures associated with bisphosphonate therapy appear to correlate with increasing awareness among the medical and lay community. Conclusion As medication experts, pharmacists play a key role in recognizing risk factors for atypical fractures, utilizing the FDA’s system to support accurate event reporting, and promoting bisphosphonate deprescribing when clinically appropriate.

[Preventive activities in women. PAPPS update 2022]

In the 2022 PAPPS update we present those specific preventive activities for women's health, except those related to cancer prevention (which are included in another document) and those aspects related to differential gender morbidity, a cross-cutting aspect for all working groups. Contraception is an essential preventive activity, considering basic the right to decide both the number of children and the time to have them. We must inform about the possible contraceptive methods, guaranteeing the monitoring of their safety, efficacy and effectiveness (tables are included on changing from one method to another to preserve contraceptive protection). We must inform about emergency contraception and propose it in the event of unprotected intercourse. All this will be done through opportunistic screening without requiring screening for thrombophilia or dyslipidemia, but for arterial hypertension. Pregnancy is an important life experience and the family doctor should not remain oblivious. We must be competent both in the preconception consultation (recommending the intake of folic acid, avoiding exposure to occupational and environmental risks, screening for certain pathologies and assessing the intake of drugs not indicated during pregnancy) and in the monitoring of pregnancy. Whether or not we monitor the pregnancy, we must not disregard its control, taking advantage of this period to promote healthy lifestyles and participating in the intercurrent processes that may occur. Menopause in general and osteoporosis in particular exemplify the strategy of medicalization of vital processes that has been followed from different instances and organizations. In our update we address the prevention and treatment of symptoms secondary to estrogen deprivation. We also propose the prevention of osteoporosis, including carrying out densitometry based on the risk of fracture in the next 10 years, and therefore densitometric screening is not recommended in women under 60 years of age. In risk assessment we recommend the use of the frax tool or better, the calibration of the risk of hip fracture with prevalence data from our setting. We linked the indication for treatment with the Z-Score (bone mineral density compared with women of the same age), as it is a condition associated with aging.

Risk Factors for Denosumab Discontinuation in Patients with Postmenopausal Osteoporosis

OBJECTIVES

Persistence with treatment is key to achieving successful treatment outcomes in patients with osteoporosis. We investigated risk factors for denosumab discontinuation in patients with postmenopausal osteoporosis (PMO).

METHODS

A total of 333 patients with PMO who had never received osteoporosis treatment were included in this study. Baseline demographics and retention rate of denosumab were evaluated in all patients. Univariate analysis was performed in patients divided into two groups according to whether they had continued or discontinued denosumab. A Cox proportional hazards model was used to determine risk factors for denosumab discontinuation.

RESULTS

Mean age was 80.7 years, body mass index (BMI) was 21.5 kg/m2, and T-scores for the lumbar spine and femoral neck were -2.7 and -2.8, respectively. The retention rate of denosumab at 36 months was 50.3%. Patients who continued denosumab were younger and had higher BMI, serum albumin (Alb) levels, and lumbar spine bone mineral density, and fewer vertebral fractures (VFs), compared with those who discontinued denosumab. The Cox proportional hazards model revealed that a low BMI, low serum Alb levels, and a high number of VFs are independent risk factors for denosumab discontinuation.

CONCLUSIONS

A low BMI, low serum Alb levels, and a high number of VFs were associated with denosumab discontinuation in patients with PMO.

Deprescribing in Palliative Cancer Care

The aim of palliative care is to maintain as high a quality of life (QoL) as possible despite a life-threatening illness. Thus, the prescribed medications need to be evaluated and the benefit of each treatment must be weighed against potential side effects. Medications that contribute to symptom relief and maintained QoL should be prioritized. However, studies have shown that treatment with preventive drugs that may not benefit the patient in end-of-life is generally deprescribed very late in the disease trajectory of cancer patients. Yet, knowing how and when to deprescribe drugs can be difficult. In addition, some drugs, such as beta-blockers, proton pump inhibitors, anti-depressants and cortisone need to be scaled down slowly to avoid troublesome withdrawal symptoms. In contrast, other medicines, such as statins, antihypertensives and vitamins, can be discontinued directly. The aim of this review is to give some advice according to when and how to deprescribe medications in palliative cancer care according to current evidence and clinical praxis. The review includes antihypertensive drugs, statins, anti-coagulants, aspirin, anti-diabetics, proton pump inhibitors, histamin-2-blockers, bisphosphonates denosumab, urologicals, anti-depressants, cortisone, thyroxin and vitamins.