Effectiveness of osteoporosis medication on site-specific fracture-risk attenuation among adults with epilepsy

Fractures in people with epilepsy: A nationwide population-based cohort study

OBJECTIVE

The objective of this study was to determine the age, gender, and site-specific prevalence of fractures in people with epilepsy (PWE) and matched general population comparators in a nationwide study in North Macedonia between 2015 and 2018.

METHODS

PWE and matched controls were selected through a systematic search of the electronic National Health System (eNHS). We determined the period prevalence (PP) of all site-specific fractures. We also calculated gender and age-specific incidence rate ratios (IRR) for various fractures. Odds ratios (ORs) and risk ratios (RR) were estimated for the number and type of ASM as well as comorbid conditions.

RESULTS

Out of 13 818 prevalent epilepsy cases, 6383 (46.2%) were females, and 7435 (53.8%) were males. 109 PWE out of 1000 had at least one fracture during the study period and ~8 people out of 1000 in the general population. The most frequent sites in terms of PP both in PWE and controls, were fractures of the lower arm, hip and femur, and lower leg. Significant differences in PP for all fracture locations were observed between PWE and controls (P < 0.001). The noticeable differences of ∼100 times higher PP were observed for fractures of the skull and jaw in PWE. IRR of any fracture in PWE was 272.84/10 000 person-years; higher in the older age groups and among people who received >2 ASM. Fracture risk was increased with the use of >2 ASM (OR: 1.56; 95% CI: 1.32-1.84 and RR: RR: 1.32). The presence of comorbidities also increased fractures risk (OR: 1.24; 95% CI: 1.10-1.38).

SIGNIFICANCE

This population-based study depicts a higher fracture prevalence in PWE compared to the general population. A higher number of ASM and the presence of comorbidities increase the risk of fractures and targeted prevention might be needed in those subgroups of PWE.

[Medicine for people with disabilities : Special features of trauma surgical care of extremity injuries in people with severe mental and physical disabilities]

Die von Bodelschwinghschen Stiftungen Bethel blicken auf eine über 150-jährige Tradition in der Behandlung von Menschen mit Behinderungen. Das traumatologische Patient*innenkollektiv ist dabei regelmäßig durch schwerste geistige und körperliche Entwicklungsstörungen und (Mehrfach‑)Behinderungen, mit und ohne Verhaltensstörungen, und internistische Begleiterkrankungen charakterisiert. Diese besondere Kombination erfordert ärztlich wie pflegerisch eine Therapie und Indikationsstellung, welche in allen Behandlungsschritten spezifisch abgewogen und angepasst werden muss. Behandlungsrichtlinien oder Empfehlungen zu diesem Patientenkollektiv existieren in der Literatur nicht. Des Weiteren kann die Behandlung von Frakturen bei Menschen mit Behinderungen nicht immer nach etablierten Konzepten erfolgen. Aufgrund einer hohen postoperativen Komplikationsrate kommt der konservativen Therapie eine entscheidende Rolle zu. Die Entscheidung zur operativen Therapie muss interdisziplinär und individuell unter Berücksichtigung sämtlicher Faktoren getroffen werden. Spezielles Augenmerk muss dabei auf das zu wählende Verfahren (Stabilität, funktionelle Bedürfnisse) gerichtet werden.

Incidence of clinical fractures: A 7-year follow-up study in institutionalized adults with epilepsy and intellectual disability

PURPOSE

To determine the incidence of clinical fractures over seven years of follow-up, in adults with epilepsy and intellectual disability, residing in a long-stay care facility.

METHODS

In 2009, all institutionalized adult patients (n = 261) were invited to undergo a Dual-energy X-ray Absorptiometry (DXA) measurement and a Vertebral Fracture Assessment (VFA). Participants were followed over seven years or until date of discharge (in case of moving from the care facility) or date of death. The patients' medical files were screened for radiology reports and staff notes, to identify clinical fractures. Fracture incidence rates (IR) were determined and compared for subgroups, by calculating incidence rate ratios. Hazard ratios were calculated to identify factors associated with fracture risk, using Cox Proportional Hazards analyses.

RESULTS

A total of 205 patients (124 male, 60.5%) aged between 18 and 88 years (median 48, IQR 34-60) were enrolled. At baseline, 92 patients (44.9%) were diagnosed with osteopenia and 65 (31.7%) with osteoporosis. Between 2009 and 2016, 30 patients (14.6%) deceased and 3 patients (1.5%) left the care facility. During follow-up, 156 clinical fractures were reported in 82 patients (40.0%). Thirty-eight patients (18.5%) had at least one major osteoporotic fracture. Overall, the IR was 11.6 fractures per 100 person-years. Fracture risk was significantly lower in patients who were wheelchair dependent than in patients who were able to walk (p<.001).

CONCLUSION

This study demonstrated that 40% of institutionalized adults with epilepsy and intellectual disability had at least one clinical fracture during seven years of follow-up, despite adequate anti-osteoporosis treatment.

The effect of age when initiating anti-seizure medication therapy on fragility fracture risk for children with epilepsy

BACKGROUND

Anti-seizure medication (ASM) is necessary to manage epilepsy and often prescribed to children and adolescents, but can lead to iatrogenic effects, including bone fragility by altering bone metabolism. Disrupting bone metabolism during crucial developmental stages could have a lasting adverse effect on bone health. Therefore, the objective of this propensity score-matched, observational cohort study was to determine if age when initiating ASM therapy across developmental stages (from pre- to post-puberty) for individuals with epilepsy was associated with an increased risk of fragility fracture.

METHODS

Data from 01/01/2011 to 12/31/2018 were extracted from Optum Clinformatics® Data Mart. Children aged 4-21 years at baseline with at least 5 years of continuous health plan enrollment were included to allow for a 1-year baseline and 4-years of follow-up. The primary group of interest included new ASM users (i.e., treatment naïve) with epilepsy. The comparison group, no ASM users without epilepsy, was matched 1:14 to new ASM users with epilepsy for demographics and baseline fracture. To provide a proxy for developmental stages, age was categorized as 4-6 (pre-puberty), 7-10 (early puberty), 11-13 (mid-puberty), 14-17 (late puberty), and 18-21 (post-puberty). Crude incidence rate (IR; per 1000 person years) and IR ratio (IRR and 95% confidence intervals [CI]) were estimated for non-trauma fracture (NTFx) for up to 4-years of follow-up.

RESULTS

Prior to stratifying by age group, the crude NTFx IR (95% CI) of 20.6 (16.5-24.8) for new ASM users with epilepsy (n = 1205) was 34% higher (IRR = 1.34; 95% CI = 1.09-1.66) than the crude NTFx IR (95% CI) of 15.4 (14.4-16.3) for no ASM users without epilepsy. The groups exhibited a different pattern of NTFx incidence with age, with new ASM users showing a more dramatic increase and peaking at 11-13 years, then decreasing with the older age groups. The crude IR and IRR were elevated for new ASM users with epilepsy compared to no ASM users without epilepsy for each age group (10% to 55% higher), but was only statistically significant for 11-13 years (IRR = 1.55; 95% CI = 1.02-2.36).

CONCLUSIONS

Children with epilepsy initiating ASM therapy may be vulnerable to fragility fracture, especially when initiating ASM around the time of puberty. Clinicians should be aware of this age-related association and consider age-appropriate adjunct bone fragility therapies.

Effect of levetiracetam and oxcarbazepine on 4-year fragility fracture risk among prepubertal and pubertal children with epilepsy

OBJECTIVE

The objective of this study was to determine whether two commonly prescribed antiseizure medications (ASMs), levetiracetam (LEV) and oxcarbazepine (OXC), were associated with an increased risk of fragility fracture in children with epilepsy when initiating therapy during a crucial period of bone development, namely, pre- and midpuberty.

METHODS

Claims data from January 1, 2009 to December 31, 2018 were extracted from the Optum Clinformatics Data Mart. Children aged 4-13 years at baseline with at least 5 years of continuous health plan enrollment were included to allow for a 1-year baseline (e.g., pre-ASM exposure) and 4 years of follow-up. Children with epilepsy who were ASM naïve were grouped based on whether ASM treatment initiation included LEV or OXC. The comparison group included children without epilepsy and without ASM exposure. Crude incidence rate (IR; n per 1000 person-years) and IR ratio (IRR; with 95% confidence interval [CI]) were estimated for nontrauma fracture (NTFx), a claims-based proxy for fragility fracture, for up to 4 years of follow-up. Cox proportional hazards regression estimated the hazard ratio (HR; with 95% CI) after adjusting for demographic variables, motor impairment, and baseline fracture.

RESULTS

The crude IR (95% CI) of NTFx was 21.5 (21.2-21.8) for non-ASM-users without epilepsy (n = 271 346), 19.8 (12.3-27.2) for LEV (n = 358), and 34.4 (21.1-47.7) for OXC (n = 203). Compared to non-ASM-users, the crude IRR of NTFx was similar for LEV (IRR = .92, 95% CI = .63-1.34) and elevated for OXC (IRR = 1.60, 95% CI = 1.09-2.35); the crude IRR of NTFx was elevated for OXC compared to LEV (IRR = 1.74, 95% CI = 1.02-2.99). The findings were consistent after adjusting for covariates, except when comparing OXC to LEV (HR = 1.71, 95% CI = .99-2.93), which was marginally statistically insignificant (p = .053).

SIGNIFICANCE

Initiating OXC, but not LEV, therapy among 4-13-year-olds with epilepsy is associated with an elevated risk of fragility fracture. Studies are needed to determine whether these children could benefit from adjunct bone fragility therapies.

The Effect of Osteoporosis Medication on Risk Attenuation of Non-Trauma Fracture Among Adults with Cerebral Palsy: A Propensity Score-Matched Observational Study

Purpose

The efficacy of osteoporosis medication on reducing the risk of non-trauma fracture (NTFx) among adults with cerebral palsy (CP) has not been comprehensively investigated. There are many logistical and biological factors that may reduce this efficacy, and therefore requires attention. The purpose of this propensity score-matched, observational cohort study was to determine if osteoporosis medication was associated with NTFx risk attenuation among adults with CP and compared to adults without CP.

Materials and Methods

Data from 07/01/2011 to 09/30/2015 were extracted from Optum Clinformatics^® Data Mart. Claims identified adults (≥18 years), CP, osteoporosis medication, pre-index NTFx (6-months), and post-index NTFx (12-months). CP without osteoporosis medication (CP_Meds-) and without CP with Meds (non-CP_Meds+; reflects "background" population) served as controls and were matched (6:1 ratio) to adults with CP with Meds (CP_Meds+; n=306). The Meds groups were further stratified by the initiation of their medication as new users or consistent users. Changes in the prevalence of NTFx from pre- to post-index periods were examined with risk ratios (RR) and the change was compared among groups using the ratio of the RR (RRR) via difference-in-difference analysis.

Results

New users with CP had: a larger risk attenuation of any NTFx compared to CP_Meds- (RRR=0.39; 95% CI=0.22-0.71), which was consistent for vertebral column/hip and lower extremities; a larger risk attenuation for NTFx of the lower extremities compared to consistent users with CP (RRR=0.22; 95% CI=0.05-0.93); and a similar risk attenuation of any NTFx compared to new users without CP (RRR=0.81; 95% CI=0.45-1.43), which was consistent for vertebral column/hip and lower extremities.

Conclusion

The findings suggest that osteoporosis medication is associated with clinically meaningful risk attenuation of NTFx, especially for new users with CP.