Use of Bisphosphonates in Older Adults: How Long Is Long Enough?

Bilateral atypical femur fractures without bisphosphonate exposure

Atypical femur fractures have common radiographic features that set them apart from more typical higher-energy subtrochanteric femur fractures. They are noncomminuted, transverse fractures with medial spiking of the femoral cortex and increased lateral cortical thickness. These fractures have been associated in the literature with the use of bisphosphonate medications. This case describes bilateral atypical femur fractures in a patient with a medical history devoid of bisphosphonate use. We present his history, co-morbidities, and subsequent treatment. From this case, we call attention to bisphosphonate use as not the only cause of subtrochanteric femur fractures with atypical features and highlight that some patients may sustain these injuries even bilaterally without use of the medications. In addition, it is important to identify this fracture type and obtain imaging of the contralateral femur to facilitate prophylactic treatment if needed.

Bisphosphonates for Osteoporosis in Patients with Renal Insufficiency: Pharmacists' Practices and Beliefs

BACKGROUND

Clinicians often face challenges in deciding how to treat osteoporosis in patients with chronic kidney disease. As background to offering guidance to health care providers, it is important to understand their practices and beliefs.

OBJECTIVES

To describe the practices and beliefs of pharmacists regarding use of bisphosphonates for patients with osteoporosis and chronic kidney disease.

METHODS

A cross-sectional survey of pharmacists working in hospitals and related health care settings was conducted. A 34-item online questionnaire was developed consisting of 4 sections: demographic characteristics, practices, beliefs, and comfort level with making decisions about osteoporosis treatment. An e-mail invitation was sent to members of the Canadian Society of Hospital Pharmacists (n = 2499) in November 2012.

RESULTS

A total of 367 pharmacists completed the survey. Most of the respondents were women (258 [70%]), had more than 10 years in practice (213 [58%]), and were providing care to 1 or more osteoporosis patients per week (212 [58%]). Over one-third (150 [41%]) stated that they would use a bisphosphonate for patients with creatinine clearance (CrCl) of 15-30 mL/min, but more than half (207 [56%]) stated that they would avoid a bisphosphonate (and recommend another medication) for patients with CrCl below 15 mL/min. Forty-eight percent (176/363) agreed that oral bisphosphonates could be used for patients with renal failure (defined as CrCl < 30 mL/min), so long as dosage adjustments are made. More than half (206/363 [57%]) believed that the adverse effects of oral bisphosphonates increase for patients with renal failure. Respondents expressed a low level of comfort in assessing and initiating osteoporosis treatment for patients with renal failure.

CONCLUSIONS

Pharmacists had varying beliefs about managing osteoporosis in patients with chronic kidney disease. This study highlights the need for practice tools and targeted education addressing the use of bisphosphonates for these patients.

Role of the Pharmacist in Medication Therapy Management Services in Patients With Osteoporosis

PURPOSE

This study aimed to review and summarize clinical trial data, updated guidelines, and expert opinions on the recommendations for drug holidays in patients being treated for osteoporosis.

METHODS

Three unique PubMed searches using the terms osteoporosis drug holiday, osteoporosis discontinuation, and osteoporosis extension produced 149 articles, of which 16 with relevance to postmenopausal osteoporosis and treatment discontinuation were selected. A separate search of 6 national societies with interest in the treatment of osteoporosis produced 2 guideline statements with specific mention of therapy duration.

FINDINGS

No pharmacologic therapy for osteoporosis should be considered indefinite. After 3 to 5 years of therapy, a comprehensive patient assessment of individualized risk for fracture should occur. In patients who are at mild to moderate risk for fracture after initial treatment, therapy with a bisphosphonate may be discontinued, whereas patients who remain at high risk for fracture should continue therapy. Although discontinuation with bisphosphonate agents may be appropriate due to mechanism of action and expected residual effects, which may last several years after discontinuation, discontinuation of shorter-acting agents (nonbisphosphonate agents) will result in a rapid reversal of therapeutic benefits and may not be appropriate. Patients who undergo a drug holiday should be monitored and reassessed for re-initiation of therapy. Caution should be employed by readers generalizing results to male patients with osteoporosis as pivotal trial data are limited to postmenopausal women with osteoporosis.

IMPLICATIONS

Pharmacists play a crucial role in ensuring that patients achieve optimal therapeutic outcomes. This achievement is partly accomplished through medication-adherence monitoring and education. Most chronic disease states require that patients remain on therapy, even when asymptomatic, for an indefinite period to meet and maintain therapeutic goals. To improve health-related outcomes, some pharmacist-managed medication therapy management programs are devoted entirely to treatment adherence. However, osteoporosis is a chronic disease state for which indefinite therapy may no longer be recommended due to potential long-term tolerability issues. It is crucial that the pharmacist understand the data and new guidelines addressing the optimal duration of therapy in osteoporotic patients so that they recognize which patients qualify for a drug holiday, do not mistakenly categorize a patient as nonadherent when therapy is stopped, and recommend when therapy should be restarted. This understanding will result in better patient management and health system cost-savings.

Bisphosphonate Drug Holidays and Fall Prevention in the Reduction of Postmenopausal Fractures

Bisphosphonates are commonly used as first-line agents in the treatment of postmenopausal bone fragility. Recently, concern has been raised regarding the risk of atypical fracture with long-term therapy. A potential solution to obtaining the benefits while minimizing the risks of bisphosphonate therapy is the use of a drug holiday, or temporary cessation of medication. For drug holidays to be an effective approach, patients must maintain fracture protection while off therapy. One way to optimize fracture protection during this time is to prevent falls. Risk of atypical fracture and bisphosphonate drug holiday will be discussed, along with a summary of the most effective fall prevention modalities.

Safety concerns with the long-term management of osteoporosis

INTRODUCTION

Postmenopausal osteoporosis is a chronic disease that exerts a significant burden on both individuals and the community. Hence, there is a requirement for long-term treatment to be associated with a positive benefit-risk balance.

AREAS COVERED

In this descriptive review, the long-term safety of calcitonin, selective estrogen receptor modulators (SERMs), bisphosphonates, denosumab and strontium ranelate was reviewed based on randomized controlled trials of 3 years or longer supplemented by extension study data and data from large, observational studies.

EXPERT OPINION

Rare adverse events become apparent with all currently available treatments for osteoporosis with long-term therapy. Due to the rarity of these adverse events and to the worldwide burden of osteoporosis, the benefit-risk balance remains in favor of the beneficial effects of treatment on an outcome rather than the probability of an adverse effect. No single antiosteoporosis agent is appropriate for all patients. Treatment decisions should be made on an individual basis, taking into account the relative benefits and risks in different patient populations.