Osteoporosis: Data insights help build better bones

• Osteoporosis is a common chronic disease among Australians aged 50 plus, yet a recent study using MedicineInsight data has shown it is underdiagnosed and undertreated
• Qualitative data from the same study have revealed gaps in knowledge among GPs, as well as attitudes and beliefs that influence osteoporosis prescribing and management
• Targeted interventions may help to address these treatment gaps and improve prescribing and adherence
• Efficient recall/reminder systems and e-health record sharing can improve the overall care and management of osteoporosis in the community

A longitudinal retrospective cohort study used MedicineInsight data from Australian general practice patients who presented to their doctor between 2011 and 2018 and were aged over 50 years (n = 203,201).

MedicineInsight is a national general practice data program that extracts longitudinal, de-identified patient data from the clinical information systems (CISs) of participating general practices.

Find out more about MedicineInsight

In depth interviews with a sample of GPs from MedicineInsight practices were also undertaken in this study. The aim was to identify current trends in osteoporosis medicine prescribing and treatment patterns, and to explore GP attitudes and beliefs about osteoporosis management.²

Read the full study: Osteoporosis management in Australian general practice: an analysis of current osteoporosis treatment patterns and gaps in practice

Prescription trends

An upward trend in osteoporosis medicine prescriptions for the patient cohort, from just under 20,000 in 2012 to nearly 35,000 in 2017, was largely due to a progressive increase in the number of denosumab prescriptions combined with a decrease in prescriptions for bisphosphonates and other osteoporosis medicines.²

Despite a steady increase in the total annual number of prescriptions for osteoporosis medicines, almost a quarter of the patients who had a recorded diagnosis of osteoporosis (n = 25,188) did not have any record of a prescription for an osteoporosis medicine.²

Managing osteoporosis medicines

Qualitative interviews with a sample of GPs working in practices across Australia identified gaps in knowledge about how to manage osteoporosis medicines to maximise their effectiveness.

Denosumab

Most GPs were aware of the need to administer denosumab every 6 months for maximum efficacy and that interrupting or stopping denosumab treatment causes rapid reversal of bone mineral density (BMD) gains and increased risk of fracture.^2,3,7,8

However, the MedicineInsight data showed that there was insufficient substitution with another osteoporosis medicine when denosumab was ceased in general practice. More than 80% of the patients who had stopped denosumab received no subsequent prescription for a bisphosphonate, potentially exposing them to rapid bone loss.²

Bisphosphonates

Planned breaks (drug holidays) for patients on long-term bisphosphonates who had responded well to treatment was a familiar concept for most GPs. However, some GPs expressed uncertainty about whether drug holidays were appropriate for their patients, how to undertake them and what follow-up was required.²

Attitudes and beliefs

The study revealed GP attitudes or beliefs about osteoporosis treatment.² These included:

• lack of clarity about benefits of initiating osteoporosis treatment to prevent fractures
• reluctance to start treatment where there was no evidence of fracture
• uncertainty about the effects of stopping osteoporosis treatment, especially denosumab
• doubt about the appropriateness of planned breaks from treatment, ie, drug holidays, especially for bisphosphonates
• choosing not to start denosumab if they thought that patients were unlikely to return for a follow-up injection.

Several patient factors potentially affecting osteoporosis management were also identified by GPs.² These included:

• poor patient awareness of osteoporosis and its consequences
• patient scepticism and reluctance to commence or continue treatment, particularly when there were no symptoms or few tangible benefits
• concerns about adverse effects
• complex dosing schedules, particularly with bisphosphonates
• cost of treatment.

Lessons learned

This data highlights the need for targeted interventions to help improve knowledge and management of osteoporosis in general practice and to address attitudes and beliefs to improve treatment choices and adherence.

The following practice points can help to optimise osteoporosis treatment and management.

1. Identify and treat patients with osteoporosis

Recognise clinical risk factors and their impact on fracture risk

Osteoporosis risk factors and recommendations for investigation and management are included in Australian guidelines, including those from RACGP and Therapeutic Guidelines, linked below. Note that a subscription is required to access Therapeutic Guidelines.

• RACGP: Osteoporosis prevention, diagnosis and management for postmenopausal women and men over 50 years of age
• Therapeutic Guidelines: Bone and metabolism. Osteoporosis and minimal trauma fracture

Consider treatment

The decision to treat is based on fracture history, BMD, T-score (Table 1), and ongoing fracture risk.^3,11

Table 1. T-score compares BMD with that of young healthy adults of same sex ^3,11

Initiate treatment based on recommendations

Osteoporosis medicines are recommended for patients:^3,11,12

• with a T-score in the normal range (–1.0 or higher) who have had MTF of the hip
• with a T-score in the normal range who have had MTF of the vertebrae and one or more risk factors for fracture (specialist advice is recommended)
• with a T-score in the normal range who have had MTF at another site (non-hip, non-vertebral) and one or more risk factors (specialist advice is recommended)
• with T-scores in the osteopenic (–1.0 to –2.5) or osteoporotic range (–2.5 or lower)
• with a T-score in the osteopenic range and MTF with one or more risk factors
• older than 65 years with a T-score in the lower osteopenic range (–2.0 to –2.5) and one or more risk factors
• who are commencing glucocorticoid therapy (≥ 7.5 mg/day prednisolone or equivalent for at least 3 months) and have a T-score of –1.5 or lower. Note that a T-score of –1.0 or lower applies under the Repatriation Pharmaceutical Benefits Scheme for veterans.

Information about osteoporosis medicine selection is available in Therapeutic Guidelines: Bone and metabolism. Osteoporosis and minimal trauma fracture

2. Emphasise impact of poor adherence

Explain the importance of adherence to osteoporosis medicines, especially denosumab, and discuss this with patients. The following examples may help.

Examples of the impact of poor adherence:

• For bisphosphonates, a retrospective cohort study reported that patients who have less than 50% of their prescriptions dispensed gained only marginal benefit from their treatment in terms of fracture risk.¹³
• For denosumab, there are case reports of multiple vertebral fractures occurring after stopping denosumab.^14,15
• Fractures were reported between 8 to 16 months (mean 11.2 months) after the last denosumab dose.¹⁵
• Poor adherence to treatment is a leading cause of fractures and hospitalisation.^7,8

Monitor treatment response and adjust treatment accordingly

Review response to treatment by checking adherence, and monitoring BMD and adverse effects at appropriate intervals.⁶

Monitoring osteoporosis treatment³

• Use actual bone mineral density values (BMD); T-scores are not appropriate for monitoring.
• Consider measuring BMD at the lumbar spine and hip:
  • 2 years after starting treatment
  • 1 to 2 years after a significant change in treatment.
• Consider more frequent BMD measurement (but not more than once a year) for patients with severe osteoporosis or high risk of bone loss, including those taking high-dose glucocorticoid therapy.
• If BMD is stable or improving, subsequent measurement is not required for at least 2 years and in some cases 5 years may be reasonable.
• If BMD decreases by more than 5% or 0.05 grams/cm² at any major site, or if a fracture occurs, consider investigation for new or unrecognised risk factors and check adherence to therapy. A change of therapy may be appropriate.
• Throughout therapy with bisphosphonates or denosumab, ensure the patient’s calcium intake is sufficient and they are vitamin D-replete.³

Stopping or interrupting bisphosphonate therapy (drug holidays)³

Long-term bisphosphonate treatment has been linked to an increased risk of skeletal adverse effects including osteonecrosis of the jaw. Limiting the duration of bisphosphonate therapy may reduce the incidence of these effects.³

• Unlike denosumab, which is rapidly reversible, bisphosphonates are retained in the bone after treatment withdrawal
• For patients not at high risk of MTF it is reasonable to consider stopping bisphosphonate therapy after 5 years (oral) or 3 years (IV).

After stopping bisphosphonate treatment, consider measuring BMD after 2 to 3 years and continuing to assess for fracture risk. The rate of decrease in BMD may vary depending on which bisphosphonate has been stopped.³

Consider restarting bisphosphonate treatment if:³

• BMD has decreased significantly, ie, decreased by 5 % or by 0.05 grams/cm² at lumbar spine, hip or femoral neck
• patient has a MTF after stopping treatment
• patient has new or worsening risk factors for fracture, such as increased falls risk.

3. Avoid interrupting denosumab without replacement

Withdrawal or interruption of denosumab treatment (dose delayed by more than 4 weeks) is associated with rapid reversal of BMD gains, treatment loss and increased risk of multiple spontaneous vertebral fracture.^3,10

• Adherence to 6-monthly dosing of denosumab is essential to prevent BMD loss between doses.³
• If denosumab treatment cannot be continued, transition to an oral bisphosphonate for at least 12 months is recommended, commencing within 4 weeks of the missed dose.^3,10
• Provide ongoing patient education and advise patients that they should not delay or omit denosumab doses.³
• Ensure efficient recall and reminder systems are part of practice protocol, especially for patients having 6-monthly denosumab injections.²
• Use My Health Record for sharing patient’s electronic health records to improve the overall care and management of osteoporosis in the community.²

4. Have efficient systems in place

• Ensure efficient recall and reminder systems are part of practice protocol, especially for patients having 6-monthly denosumab injections.²
• Use My Health Record for sharing patient’s electronic health records to improve the overall care and management of osteoporosis in the community.²

Osteoporosis is a common chronic condition that remains underdiagnosed and undertreated. MedicineInsight data highlights that most patients who stop denosumab treatment have no record of a subsequent prescription for another osteoporosis medicine.

Adherence to osteoporosis medicines and a streamlined transition from denosumab to an oral bisphosphonate can help to prevent bone loss and fractures for patients living with osteoporosis.

• NPS MedicineWise Osteoporosis: recognising those at risk
• NPS MedicineWise Why osteoporosis matters
• Osteoporosis Australia: Osteoporosis costing all Australians, 2012–2022. A new burden of disease analysis
• RACGP Osteoporosis Guidelines and flowchart. Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age.
• My Health Record in general practice

• NPS MedicineWise Bone health action plan
• NPS MedicineWise Managing osteoporosis
• NPS MedicineWise Osteoporosis explained
• My Health Record for patients