Australian patients with osteoporosis and very high fracture risk may be missing out on useful anabolic therapy due to ‘treatment inertia’ on the part of their treating specialists, researchers say.

Based on survey data, they argue that Australian clinicians’ perceptions of these patients also appear to be heavily influenced by PBS reimbursement criteria, despite these often clashing with international guidelines.

Some 67 endocrinologists, rheumatologists and other specialists answered the poll, which was taken after a series of drug company-sponsored webinars on anabolic treatments for osteoporosis in early 2021.

An aggregate of responses suggested they perceived a typical patient with a very high risk (VHR) of fragility fracture as being a woman in her 80s, with traits including:

• Living at home
• Diagnosed with osteoporosis 5-10 years ago
• Treated 1-5 years, typically with denosumab

Most also had two or more fragility fractures and over half had a current T-score below -3.0 SD, while about the same amount had suffered a symptomatic vertebral fracture in the past 12 months while on adequate regimen of osteoporosis medication.

But significantly, treatment patterns described for those patients considered to be at VHR of fracture highlighted a “mismatch” between the patient’s eligibility for anabolic therapy (64%) and having actually been prescribed such treatment in the past (21%), the researchers said.

“The proportion of patients considered eligible for anabolic therapy was threefold higher than the proportion of patients who had previously been prescribed an anabolic therapy,” they wrote in IMJ (link here)

“This represents a treatment gap and raises the question of inertia for anabolic prescription even among experts.”

Another interesting finding was how closely the clinicians’ responses aligned with the PBS criteria for anabolic therapies, even where this departed from the overall evidence base, the authors noted.

This “may suggest an influence of the reimbursement criteria on clinicians’ understanding of VHR”, they said.

“Despite the body of evidence that supports the use of anabolic treatment as first-line therapy in VHR patients, given the restrictions of the reimbursement criteria and the high cost of anabolic therapy for privately funded prescriptions, the clinicians’ recall patient may also have been biased towards the reimbursement criteria by their clinical experience,” they wrote.

“This was even found after an instructive webinar discussing the specific patient groups to benefit from anabolic therapies, distinct from reimbursement criteria.”

They added: “The restrictions of the reimbursement criteria are a major barrier for prescribing anabolic therapies in the sequence that is supported by key clinical studies.”

“Thus, it heavily impacts the working definition of VHR in the Australian context.”

On the issue of treatment inertia, the authors noted similar issues had been reported in other chronic conditions when patients needed to be given daily injectable therapies after having failed less onerous first-line treatment.

“Prior to the time of our survey, teriparatide was the only available anabolic agent and prescription rates of this agent were low according to the Australian Medicare claims database,” they wrote.

“There may have been other patient factors that led to low rates of anabolic therapy prescription, for example, low acceptance of teriparatide or daily injections, or cost of therapy.”

The authors – Associate Professor Christian Girgis and Professor Peter Ebeling – recommended that local guidelines be developed to further characterise groups of VHR fracture patients and enable clinicians to be “more confident, overcome inertia and be proactive in prescribing anabolic therapy”.