Osteoporosis medication underused: but there are solutions

An audit of bone protection medication (BPM) use in Australia and New Zealand after a hip fracture has shown an urgent need to improve management to help prevent subsequent fractures.

The review of 55,618 patients in the Australian and New Zealand Hip Fracture Registry (ANZHFR) between 2016 and 2020 found 8.9% of Australian patients were on BPMs at admission, increasing to 22.4% on discharge.

Similarly in New Zealand, 9.1% of patients were on BPMs on admission and increasing to 27.8% on discharge.

“Initiation of BPM treatment following contact with the healthcare system highlights the potentially effective role that healthcare professionals can play in bridging the acknowledged treatment gap in secondary fracture prevention,” the study said.

Younger and healthier patients were less likely to be taking BPM however on the flip side, residents in aged care facilities, those with impaired cognition, a history of post-operative delirium or waiting on a specialist falls assessment were also less likely to be taking BPM.

The most common reason for not having administered BPM was “low level of vitamin D and awaiting levels to increase” in Australia (13.3%) and “poor renal function” in New Zealand (14.8%).

The study, published in Archives of Osteoporosis [link here], said the costs of bisphosphonates and denosumab can be barriers for hospital-initiated BPM treatment in Australia.

“Additionally, patient and clinician preferences following inpatient admission and complexities surrounding discharge medication prescription (e.g., some GP failure to administer repeat prescriptions after inpatient BPM administration) may also contribute to low uptake of BPM treatment.”

Meanwhile a NSW study has found adopting a standardised protocol for osteoporosis treatment in patients admitted for hip fracture was effective in improving treatment rates while being relatively safe and inexpensive.

The protocol, developed collaboratively between geriatric medicine and endocrinology departments at Concord Hospital, aimed to provide eligible patients with anti‐resorptive treatment during their admission for hip fracture.

“Prior to implementing our protocol, inpatient osteoporosis treatment was provided at the discretion of individual hospital physicians. Most commonly, this would be deferred as a follow‐up recommendation with the patient’s general practitioner.”

Yet the majority of returning patients did not have their osteoporosis addressed.

The study, published in Aging Medicine [link here], compared 52 patients admitted April-June 2018 prior to the introduction of the protocol and 52 patients admitted from January 2020 after implementation of the protocol.

“Within 2  years of introducing the new protocol, the proportion of patients receiving bone‐protective medication prior to discharge improved from <5% to 60%,” the investigators including Professor Marcus Seibel said.

“Thus, treatment during the acute admission ensured there was no potential for delaying anti-resorptive therapy due to delayed or missed follow-up.”

Positive features of the protocol included the use of high-dose vitamin D replacement therapy for the rapid normalisation of levels in deficient patients, supporting adherence by administering a yearly BPM treatment (IV zoledronic acid), and not delaying treatment for nonessential investigations such as bone densitometry.

“The protocol triggers a simple and inexpensive intervention that resulted in a marked improvement in osteoporosis treatment rates that can easily be translated to other minimal trauma fractures,” they concluded.

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