Improvement in health-related quality of life in osteoporosis patients treated with teriparatide

Association of gastrointestinal events with quality of life and treatment satisfaction in osteoporosis patients: results from the Medication Use Patterns, Treatment Satisfaction, and Inadequate Control of Osteoporosis Study (MUSIC OS)

The purpose of this study was to assess the association of GI events with HRQoL and treatment satisfaction. The effect of baseline GI events persisted through 1 year of follow-up, as indicated by lower EQ-5D, OPAQ-SV, and treatment satisfaction scores among patients with vs without baseline GI events. The presence of GI events is an independent predictor of decreased HRQoL and treatment satisfaction in patients being treated for osteoporosis.

INTRODUCTION

The goal of this study was to assess the association of gastrointestinal (GI) events with health-related quality of life (HRQoL) and treatment satisfaction in patients being treated for osteoporosis.

METHODS

MUSIC OS was a multinational, prospective, observational study examining the impact of GI events on osteoporosis management in postmenopausal women. In this analysis, HRQoL and treatment satisfaction were assessed at baseline, 6, and 12 months and compared between patients with and without GI events. Covariate-adjusted scores were calculated using multivariate least-squares regression analysis, and differences between the mean scores of patients with and without baseline and post-baseline GI events were determined.

RESULTS

Among the 2959 patients in the analysis, unadjusted scores at each time point were lower (i.e., worse) for patients with GI events than patients without GI events. In adjusted analyses, the effect of baseline GI events persisted through 1 year of follow-up, as indicated by lower EQ-5D and OPAQ-SV scores at 12 months among patients with vs without baseline GI events (-0.04 for the EQ-5D utility score, -5.07 for the EQ-5D visual analog scale, -3.35 for OPAQ physical function, -4.60 for OPAQ emotional status, and -8.50 for OPAQ back pain; P ≤ 0.001 for all values). Decrements in month 12 treatment satisfaction scores were -6.46 for patients with baseline GI events and -7.88 for patients with post-baseline GI events.

CONCLUSIONS

The presence of GI events is an independent predictor of decreased HRQoL and treatment satisfaction in patients being treated for osteoporosis.

Exploring the nurse practitioner role in managing fractures in long-term care

The purpose of this study was to assess the current level of involvement of nurse practitioners (NPs) in activities related to preventing and managing fractures in long-term care (LTC). This study used a sequential explanatory mixed methods design that included two phases-a cross-sectional survey followed by qualitative interviews. A final sample of 12 NPs completed the online survey for a response rate of 67%. Eleven of the 12 NPs who completed the survey agreed to participate in a follow-up interview. NPs reported that they were quite engaged in managing fractures in LTC; specifically, they were most active in caring for residents post-fracture. NPs described their role as being holistic in nature in their assessment and treatments related to managing fractures. The findings from this mixed method study add to the growing body of knowledge related to how NPs manage fractures in LTC.

Study description and baseline characteristics of the population enrolled in a multinational observational study of extended teriparatide use (ExFOS)

OBJECTIVE

To better characterize patients who are currently being prescribed teriparatide in Europe, this article describes the study design and baseline characteristics of participants of the Extended Forsteo * Observational Study (ExFOS).

RESEARCH DESIGN AND METHODS

ExFOS is a noninterventional, multicenter, prospective, observational study in men and women with osteoporosis treated with teriparatide during the course of normal clinical practice for up to 24 months and with a post-treatment follow-up of at least 18 months.

MAIN OUTCOME MEASURES

Baseline characteristics, including history of fracture and back pain, and health-related quality of life (HRQoL, assessed using the EuroQol-5 Dimension [EQ-5D]).

RESULTS

Of 1607 patients enrolled, 90.9% were women. At baseline, mean (standard deviation [SD]) age was 70.3 (9.8) years, and 85.8% of patients had a history of fracture (64.7% with ≥2 fragility fractures). Of those with historic fractures, 90.8% had vertebral fractures (67.8% had thoracic fractures). The mean (SD) of reported bone mineral density T-scores were -3.0 (1.2), -2.4 (1.0), and -2.5 (0.9) for lumbar spine, total hip (left), and femoral neck (left), respectively. Overall, 39.3% of patients had experienced ≥1 fall during the 12 months before enrollment. At baseline, 11.4% of patients were osteoporosis-treatment naïve and 15% were currently using glucocorticoids. The mean (SD) visual analog scale score for back pain during the last month was 50.7 (26.9), and 62.1% of patients experienced daily or almost daily back pain. The median EQ-5D health state value at baseline was 0.62 (first and third quartiles: 0.19, 0.74).

CONCLUSIONS

Baseline characteristics of the ExFOS study cohort indicate that patients prescribed teriparatide in Europe have severe osteoporosis with highly prevalent vertebral fractures, frequent and disabling back pain, and a poor HRQoL, despite previous pharmacotherapy for osteoporosis. Limitations include non-randomization, lack of a comparator group, and patient self-report for data on prior medication and fracture history.

Effective osteoporosis treatment with teriparatide is associated with enhanced quality of life in postmenopausal women with osteoporosis: the European Forsteo Observational Study

Background

To describe changes in health-related quality of life (HRQoL) of postmenopausal women with osteoporosis treated with teriparatide for up to 18 months and followed-up for a further 18 months, and to assess the influence of recent prior and incident fractures.

Methods

The European Forsteo Observational Study (EFOS) is an observational, prospective, multinational study measuring HRQoL using the EQ-5D. The primary objective was to assess changes in HRQoL during 36 months in the whole study population. A secondary post-hoc analysis examined fracture impact on HRQoL in four subgroups classified based on recent prior fracture 12 months before baseline and incident clinical fractures during the study. Changes from baseline were analysed using a repeated measures model.

Results

Of the 1581 patients, 48.4% had a recent prior fracture and 15.6% of these patients had an incident fracture during follow-up. 10.9% of the 816 patients with no recent prior fracture had an incident fracture. Baseline mean EQ-VAS scores were similar across the subgroups. In the total study cohort (n = 1581), HRQoL (EQ-VAS and EQ-5D index scores) improved significantly from baseline to 18 months and this improvement was maintained over the 18-month post-teriparatide period. Improvements were seen across all five EQ-5D domains during teriparatide treatment that were maintained after teriparatide was discontinued. Subjects with incident clinical fractures had significantly less improvement in EQ-VAS than those without incident fractures. Recent prior fracture did not influence the change in EQ-VAS during treatment.

Conclusions

EFOS is the first longitudinal study in women with severe postmenopausal osteoporosis in the real world setting to show a substantial improvement in HRQoL during teriparatide treatment that was sustained during subsequent treatment with other medications. The increase in HRQoL was lower in the subgroups with incident fracture but was not influenced by recent prior fracture. The results should be interpreted in the context of the design of an observational study.

Vertebral fracture assessment scans enhance targeting of investigations and treatment within a fracture risk assessment pathway

Vertebral fracture assessment (VFA) scanning is a useful tool to aid vertebral fracture identification. In this evaluation, we show that introduction of a comprehensive fracture risk assessment pathway incorporating VFA has enhanced diagnosis of vertebral fractures and improved targeting of investigations and treatment.

INTRODUCTION

Vertebral fractures are a common manifestation of osteoporosis and are associated with an increased risk of future vertebral and non-vertebral fractures. VFA is a method of imaging the thoraco-lumbar spine and a useful tool to aid vertebral fracture identification. In August 2008, a new one-stop pathway was introduced incorporating VFA and laboratory investigations at the time of bone mineral density assessment. The aims of this evaluation were to evaluate the clinical utility of VFA in identifying vertebral fractures which had not presented clinically and to evaluate the impact of this on management.

METHODS

We performed a retrospective 6-month review of the new pathway focussing on those patients undergoing VFA who were suspected to have a vertebral fracture. The outcomes of VFA, spinal X-rays and investigations were evaluated.

RESULTS

Three thousand five hundred twenty-six individuals underwent fracture risk assessment over a 6-month period, of which 1,833 underwent VFA. Previously undiagnosed vertebral fractures were found in 202 individuals (36 were in retrospect apparent on prior imaging, and 29 were new vertebral fractures in patients with pre-existing vertebral fractures). Diagnosis of a vertebral fracture led to further investigation in all individuals and altered management in 59 (29 %) individuals. A potentially modifiable underlying cause was found in 42 (21 %).

CONCLUSIONS

Introduction of a fracture risk assessment service incorporating VFA and a one-stop pathway has enhanced vertebral fracture identification and targeting of treatment and management.

Quality of life measurements in patients with osteoporosis and fractures

To review all specific questionnaires regarding quality of life in osteoporosis and to describe their distinctive indications, we searched Medline, the Scientific Electronic Library Online database, and the Latin-American and Caribbean Health Sciences Literature database. Nine specific questionnaires related to osteoporosis quality of life were found: 1) the Women's Health Questionnaire, 2) Osteoporosis Quality of Life Questionnaire, 3) Osteoporosis Assessment Questionnaire, 4) Osteoporosis Functional Disability Questionnaire, 5) Quality of Life Questionnaire of the European Foundation for Osteoporosis, 6) Osteoporosis-Targeted Quality of Life Questionnaire, 7) Japanese Osteoporosis Quality of Life Questionnaire, 8) the 16-item Assessment of Health-Related Quality of Life in Osteoporosis, and 9) the Quality of Life Questionnaire in Osteoporosis (QUALIOST™). The Quality of Life Questionnaire of the European Foundation for Osteoporosis is the osteoporosis-specific questionnaire most commonly used in the literature. The Quality of Life Questionnaire of the European Foundation for Osteoporosis and the Osteoporosis Quality of Life Questionnaire are targeted more toward fracture assessment, and the Osteoporosis Functional Disability Questionnaire can be used for longitudinal studies involving exercise. In the present study, the authors summarize all of the specific questionnaires for osteoporosis and demonstrate that these questionnaires should be selected based on the objectives to be evaluated. Osteoporosis-specific quality of life questionnaires should be validated in the language of the country of origin before being used.

Individualizing osteoporosis therapy

Guidelines for osteoporosis treatment are available; however, these guidelines suggest when to treat patients, without specific recommendations on what drugs to prescribe in various situations. Choice of osteoporosis therapy should be individualized based on consideration of the efficacy, safety, cost, convenience (i.e., dosing regimen and delivery), and other non-osteoporosis-related benefits associated with each agent. Bisphosphonates, administered orally or intravenously, should be considered first-line therapy, particularly in older patients, owing to their efficacy across multiple skeletal sites; however, there are potential short- and long-term safety concerns. Selective estrogen receptor modulators should be considered for younger postmenopausal women at greater risk for vertebral than hip fractures or as second-line therapy in women who cannot tolerate first-line therapies. Low-dose hormone therapy may be appropriate as prevention in women with menopausal symptoms at lower fracture risk. Calcitonin, with its relatively benign safety profile, may be appropriate for elderly women who may have difficulty following the complex dosing schedules of oral bisphosphonates. Anabolic therapies such as teriparatide should be considered for high-risk patients. Strontium ranelate (approved outside of North America), with both anabolic and antiresorptive properties, may be appropriate for women who cannot tolerate or are unable to take bisphosphonates. Denosumab is a monoclonal antibody appropriate for women at high fracture risk or who have failed other osteoporosis therapies, and may be considered in patients with renal insufficiency. It will be important to incorporate newer agents (e.g., bazedoxifene, tissue selective estrogen complex) into this individualized treatment paradigm to optimize clinical outcomes in patients with osteoporosis.

Use of recombinant human parathyroid hormone(1-84) in patients with postmenopausal osteoporosis: a prospective, open-label, single-arm, multicentre, observational cohort study of the effects of treatment on quality of life and pain--the PROPOSE study

BACKGROUND AND OBJECTIVE

Osteoporosis is a progressive bone disorder. Its medical therapy typically involves calcium, vitamin D and antiresorptive drugs. The anabolic parathyroid hormones (PTHs) represent a major advance since they stimulate new bone formation. Two forms of recombinant human PTH (rhPTH) have been evaluated: the 34-amino acid fragment rhPTH(1-34) and the intact 84-amino acid form rhPTH(1-84), the latter being marketed as Preotact®. Osteoporosis leads to increased bone fragility and susceptibility to fracture. Additionally, the disease is often accompanied by pain and a reduced quality of life (QOL). These aspects have rarely been addressed in previously published studies of PTH, which have instead focused on bone density and fractures. The aim of the present study was to evaluate therapy with rhPTH(1-84) in the treatment of osteoporosis in postmenopausal women under everyday practice conditions with emphasis on patients' QOL and pain.

METHODS

The study was performed as a prospective, open-label, single-arm, multicentre, observational cohort study that included postmenopausal women in whom treatment with rhPTH(1-84) was newly initiated. Patients were to be treated with rhPTH(1-84) for 12 months at a dose of 100 μg, administered once daily as a subcutaneous injection. The primary efficacy endpoint was the total score on the Quality of Life Questionnaire of the European Foundation for Osteoporosis, 41-item version (QUALEFFO-41). Secondary efficacy criteria were QUALEFFO-41 subscale scores, patients' assessments of pain on visual analogue scales (range 0-100), and performance on the chair rising test.

RESULTS

112 patients were included in the safety and in the intent-to-treat (ITT) efficacy analyses. Sixty-six patients finished the 1-year period (per-protocol group). All ITT patients were female with a mean age of 72 years and a mean duration of osteoporosis of 73 months. During the study, all QUALEFFO-41 scales improved significantly: in the ITT group, the mean total score improved from 49.8 to 41.3 points. In the ITT population, mean pain at rest improved significantly by about 20% and mean pain on movement by about 36%. When patients who took at least one dose of pain medication were compared with those who took no pain medication during the study, it was evident that pain reduction did not occur only as a result of taking pain medication: use of rhPTH(1-84) was associated with a similar pain reduction in both subgroups. The most frequent adverse events (AEs) were hypercalcaemia (12.5% of patients) and nausea and vomiting (10.7% of patients). AEs caused 16% of patients to discontinue during the 12-month study period.

CONCLUSION

This 12-month study carried out in a typical sample of postmenopausal women with osteoporosis showed that treatment with rhPTH(1-84) is safe. The present study, which is one of the first to investigate QOL and pain during PTH treatment systematically, also showed that rhPTH(1-84) improves QOL and reduces pain, thereby reducing the burden of osteoporotic symptoms for patients. These results, however, need to be verified in a controlled clinical trial. [ClinicalTrials.gov Identifier: NCT00515593].

A comparison of strontium ranelate and PTH(1-84)

Evaluation of: Quesada-Gómez JM, Muschitz C, Gómez-Reino J, Greisen H, Andersen HS, Dimai HP. The effect of PTH(1-84) or strontium ranelate on bone formation markers in postmenopausal women with primary osteoporosis: result of a randomized, open-label trial. Osteoporosis Int. DOI: 10.1007/s00198-010-1460-6 (2010) (Epub ahead of print). A recent article compared parathyroid hormone (PTH[1-84]) and strontium ranelate with respect to their effects on bone formation and bone resorption markers, a study performed with the aim of shedding light on the potential differences in the mode of action of these two compounds. This study found that PTH(1-84) induces robust inductions of both the bone formation markers N-terminal propeptide of type I collagen and alkaline phosphatase, and the resorption marker c-terminal crosslinked telopeptide of type I collagen (CTX-I), data that correlate well with previous publications. However, for strontium ranelate, no induction of markers was observed. Furthermore, although the data were not significant, serum calcium levels in the two treatment groups exhibited opposing trends, with PTH(1-84) increasing these as expected and with strontium ranelate decreasing them. These data indicate that strontium ranelate utilizes another mode of action to the induction of turnover seen with PTH(1-84). Finally, a trend towards improved quality of life was seen with PTH(1-84), while strontium ranelate did not change these parameters. This article is a useful addition to the ongoing debate on how best to possibly treat osteoporosis.

Postmenopausal women with osteoporosis: experience when treated with teriparatide in clinical practice

OBJECTIVE

To observe and compare back pain and health-related quality of life (HRQoL) in postmenopausal women with a prior unsatisfactory response to antiresorptive therapy, treated with teriparatide (TPTD) or alternative treatments in normal clinical practice.

RESEARCH DESIGN AND METHODS

Prospective, observational, multicentre, 24-month study of postmenopausal women with osteoporosis. A back pain and HRQoL questionnaire (European Quality of Life Questionnaire, EQ-5D) including visual analogue scale (VAS) was completed at each visit.

RESULTS

A total of 153 patients were enrolled, 105 patients started TPTD treatment during the study (TPTD cohort) and 48 patients did not take TPTD treatment at any time during the study (non-TPTD cohort). Four patients did not meet the inclusion criteria for the study. Of the patients in the non-TPTD cohort, 31 (68.9%) took antiresorptives during the study. The patients selected by the investigator for teriparatide treatment were distinctly different from those not selected. At baseline, the mean back pain VAS was greater in the TPTD than the non-TPTD cohort, 64  mm and 42 mm, respectively (p < 0.001). During the study, compared with baseline, the mean back pain VAS decreased in the TPTD cohort at all visits (p < 0.001). In the non-TPTD cohort, a transitory decrease in the mean after 12 months was observed (-10 mm, p = 0.023) only. After 24 months, the mean back pain VAS improved in the TPTD cohort (-36 mm, p < 0.001) while no change was observed in the non-TPTD cohort (-4 mm, p = 0.467). At baseline, the mean EQ-VAS was lower in the TPTD than in the non-TPTD cohort, 40.8 and 55.2, respectively (p < 0.001). After 24 months, EQ-VAS improved in both cohorts (TPTD 34, p < 0.001 and non-TPTD 9, p = 0.026).

CONCLUSIONS

TPTD-treated patients had more back pain and lower HRQoL at baseline. In the TPTD cohort the mean value was consistently and significantly improved in back pain and quality of life. In the non-TPTD cohort, the mean improvement in back pain and QoL was inconsistent possibly due to the initially higher QoL and lower back pain leaving less room for improvement. These results should be interpreted in the context of limitations related to a non-randomised observational study.

Role of teriparatide in treatment of glucocorticoid-induced osteoporosis

Glucocorticoids are commonly used in various fields within medicine. One of their most common and clinically significant side effects is glucocorticoid-induced osteoporosis (GIOP). GIOP is a disease leading to progressive decreases in bone mineral density, decreased bone strength, and increased risk of skeletal fractures. GIOP has a significant impact on the morbidity and health-related quality of life of the patients it affects. Glucocorticoids have deleterious effects on bone through promoting osteoblast apoptosis and inhibiting osteoblastogenesis. Teriparatide exerts anabolic effects on bone, so it is understandable why teriparatide is thought to be a rational treatment option. Clinical studies have indicated teriparatide is efficacious in the treatment of GIOP to improve bone mineral density values at the lumbar spine and femoral neck. Some evidence also suggests teriparatide may reduce rates of vertebral fractures in GIOP patients. Overall, this review of the current clinical evidence suggests teriparatide may be an efficacious and promising agent in the treatment of GIOP.

The use of PTH in the treatment of osteoporosis

Anabolic drugs have recently widened therapeutic options in osteoporosis treatment, as they influence processes associated with bone formation to a greater extent and earlier than bone reabsortion. They positively affect a number of skeletal properties besides bone density, as intermittent administration of parathyroid hormone (PTH) results in an increase in the number and activity of osteoblasts leading to an increase in bone mass and improvement in skeletal architecture at both the trabecular and cortical bone. Human recombinant parathyroid hormone (hrPTH 1-84) and human recombinant PTH peptide 1-34 (teriparatide) belong to this group. The objective of this paper is to review PTH actions, benefits and adverse effects, action on biochemical markers, combination therapy with antiresorptive agents, impact of antiresorptive therapy prior to anabolic treatment, sequential treatment, and effect on glucocorticoid-induced osteoporosis.

Bone T-scores and functional status: a cross-sectional study on German elderly

Background

We explore the association between bone T-scores, used in osteoporosis diagnosis, and functional status since we hypothesized that bone health can impact elderly functional status and indirectly independence.

Methods

In a cross-sectional study (2005–2006) on community dwelling elderly (> = 75 years) from Herne, Germany we measured bone T-scores with Dual-energy X-ray Absorptiometry, and functional status indexed by five geriatric tests: activities of daily living, instrumental activities of daily living, test of dementia, geriatric depression score and the timed-up-and-go test, and two pooled indexes: raw and standardized. Generalized linear regression was used to determine the relationship between T-scores and functional status.

Results

From 3243 addresses, only 632 (19%) completed a clinical visit, of which only 440 (male∶female, 243∶197) could be included in analysis. T-scores (−0.99, 95% confidence interval [CI], −1.1–0.9) predicted activities of daily living (95.3 CI, 94.5–96.2), instrumental activities of daily living (7.3 CI, 94.5–96.2), and timed-up-and-go test (10.7 CI, 10.0–11.3) (P< = 0.05). Pooled data showed that a unit improvement in T-score improved standardized pooled functional status (15 CI, 14.7–15.3) by 0.41 and the raw (99.4 CI, 97.8–101.0) by 2.27 units. These results were limited due to pooling of different scoring directions, selection bias, and a need to follow-up with evidence testing.

Conclusions

T-scores associated with lower functional status in community-dwelling elderly. Regular screening of osteoporosis as a preventive strategy might help maintain life quality with aging.