Clinicians Could be Missing the Mark When Prescribing Osteoporosis Therapies

Sarah Cromer, MD

New research presented at ENDO 2021 is providing clinicians with insight into the prescribing practices for osteoporosis medications and suggesting current practices could be falling short for many patients.

An analysis of claims data from more than 1.4 million patients, the Massachusetts General Hospital-led study provides insight into prescribing trends of newer agents, such as denosumab, and returned results suggesting fewer than 10% of commercially insured patients who experienced a hip fracture were prescribed any osteoporosis treatments within 6 months their fracture.

“This very low rate of treatment with bone-directed medications to prevent future fractures is concerning,” said lead investigator Sara Cromer, MD, an endocrinology fellow at Massachusetts General Hospital, in a statement. “This is analogous to providing no therapy to lower blood pressure or cholesterol after a heart attack.”

Despite the introduction of new osteoporosis therapies, few studies have provided clinicians with perspective related to temporal trends in the prescribing of these newer therapies. With a greater understanding of these trends, organizations and individual clinicians would be greater equipped to address any potential issues and, with this in mind, Cromer and colleagues from Mass General designed the current study to fill this apparent knowledge gap.

For their analysis, investigators performed a search of the Clinformatics Data Mart database of individuals older than 50 years of age prescribed any osteoporosis medication during each quarter from January 1, 2009 through March 31, 2020. In total, investigators identified a total of 15.48 million unique prescription or medication administration claims from 1.46 million unique individuals.

For the purpose of their study, investigators planned subgroup analyses that limited the population to those with an ICD code for osteoporosis in the current or previous three quarters and without codes for active malignancy and another with a population limited to those with an ICD code from an oncology provider for a malignancy likely to metastasize to bone during the current or previous quarter.

Of the nearly 1.5 million patients included in the study, 89% were women, and 71% were over the age of 65 years, with the mean age of the study cohort being 69 years. Representing more than 50% of all treated individuals and use increasing over time, alendronate was the most common medication used during the study period. Additionally, the initial analysis suggested bisphosphonate use declined steadily during the study period while the percentage of users receiving zoledronic acid doubled, but investigators pointed out the overall use remained at less than 5%.

Further analysis indicated a rapid adoption of denosumab following its approval in 2010. Specifically, investigators noted use among 10% of those receiving osteoporosis medications by 2015 and this rose to 15% in 2018. When comparing those with an ICD code for osteoporosis, investigators found similar trends to those seen with the overall cohort.

In their subgroup analysis of patients with an active malignancy, results indicated alendronate and zoledronic acid were used in about 30% of individuals at the onset of the study but the use of both declined over the next decade. Meanwhile, use of denosumab increased after introduction to the point where usage rates surpassed both bisphosphonates by 2013 and now represent approximately 50% of all bone-directed medication use in the study’s malignancy cohort.

With so much variation in prescribing practices in the past decade, Cromer noted the importance of a risk-benefit discussion with patients before initiating or changing osteoporosis therapies for older patients.

“While denosumab is highly effective at improving bone density and preventing fracture, it has also been known for several years that there is an increase in spinal fractures if denosumab is discontinued without follow-up treatment, and sometimes even with follow-up treatment,” Cromer added. “This safety concern does not seem to be reflected in medication use as of early 2020, the end of our study.”

This study, “Temporal Trends in Prescribing of Bone-Directed Therapies in the United States, 2009-2020,” was presented virtually as part of ENDO 2021.