Background/Purpose: Osteoporosis is a widely prevalent but underrecognized condition. Oral bisphosphonates are considered first-line treatment of osteoporosis in men and women however long term use is associated with potential adverse effects. In patients taking bisphosphonates for at least 5 years, it is generally recommended that the need for continued bisphophonate therapy be reevaluated and a drug holiday be considered.
Methods: We conducted a computerized retrospective cohort study of all veterans, male and female > 50 years of age at the Cleveland VA Medical Center receiving a prescription for an oral bisphosphonate for greater than 5 years. Medication compliance was determined by a medication possession ratio (MPR) greater than 0.8 over 5 years (MPR= total number of days supplied/total number of days since first fill). We excluded patients receiving bisphosphonates for Paget’s disease or an indication other than osteoporosis/osteopenia (ICD9 codes 733.00, 733.90,733.01, 733.02). We identified whether prescribers were rheumatologists or primary care providers. We reviewed laboratory testing for serum 25 (OH) D3 at any time during bisphosphonate therapy, and VA pharmacy prescriptions for Calcium and Vitamin D supplementation. Chart review of clinical notes and radiology reports was performed to determine if baseline and follow-up bone mineral densitometry (BMD) were obtained and documented.
Results: 100 patients met inclusion criteria, 78 male and 22 female, mean age 76 years (range 50-96). The diagnosis was osteoporosis in 54%, osteopenia in 21%, and not documented in 23%. The most commonly prescribed bisphosphonate was alendronate (71%). The duration of bisphosphonate therapy ranged from 5 to 14 years (mean 8 years).
|
Prescription of oral bisphosphonate by rheumatologist |
Prescription of oral bisphosphonate by primary care provider |
|||
|
Number of patients (total N=100) |
n=5 |
% |
n=95 |
% |
|
Documentation of BMD at initiation of bisphosphonate |
4 |
80 |
44 |
46.3 |
|
Documentation of follow-up BMD |
5 |
100 |
37 |
38.9 |
|
Glomerular filtration rate < 30 ml/min |
0 |
0 |
3 |
3.2 |
|
Serum level of 25(OH)D3 |
5 |
100 |
60 |
63.1 |
|
Active order for Calcium |
5 |
100 |
71 |
74.7 |
|
Active order for Vitamin D |
5 |
100 |
72 |
75.7 |
Conclusion: The large majority (95%) of patients on long-term bisphophonate therapy in this veteran population were managed by PCPs rather than rheumatologists (5%). In comparison to patients managed by rheumatologists, patients managed by PCPs had low frequency of BMD documentation at initiation of therapy and in follow-up, suboptimal measurement of serum 25(OH)D3, and suboptimal Calcium and vitamin D supplementation. Our study was limited by possible use of non-VA Calcium and Vitamin D supplementation, and possible use of non-VA BMDs in patients living in areas distant from the medical center. Future studies should be directed to educational outreach to PCPs and use of computerized clinical reminders at the time of prescription renewal.
Disclosure:
M. Pioro,
None;
S. Ogorzaly,
None;
M. Mattar,
None.
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ACR Meeting Abstracts - https://acrabstracts.org/abstract/patterns-of-use-of-long-term-5-years-oral-bisphophonate-prescription-among-primary-care-providers-and-rheumatologists-for-the-treatment-of-osteopenia-and-osteoporosis-in-a-veteran-population/