Pharmacotherapy use among postmenopausal women who had osteoporosis, or a history of fractures, was found to be suboptimal in a post hoc analysis of Women's Health Initiative clinical trials data, even though treatment guidelines are well-established.
Only 21.6% of the women reported using appropriate pharmacotherapy other than estrogen to reduce future fractures.
Researchers at the University of Florida College of Medicine in Gainesville, and other centers noted that some of the women may have had contraindications to treatment, but that was unlikely to account for the majority who were not receiving treatment after the diagnosis of osteoporosis or fracture.
They presented their findings in the.
The researchers evaluated information from participants' visits before, and immediately after, their first fracture event or osteoporosis diagnosis for medication use. They used a full logistic regression model to identify factors predictive of osteoporosis medication use.
Fracture outcomes included hip, clinical spine, forearm, wrist, and total fractures that occurred after enrollment.
The researchers defined osteoporosis treatment as the use of an FDA-approved osteoporosis medication available during the study period: bisphosphonates (alendronate, ibandronate, risedronate, etidronate, and zoledronic acid), recombinant human parathyroid hormone (teriparatide), calcitonin, selective estrogen receptor modulators or SERMS (raloxifene), or any combination of the medications. Tamoxifen was included because data suggested efficacy in fracture prevention in postmenopausal women. Estrogen/hormone therapy was not included as osteoporosis treatment.
Vitamin D and calcium intake were considered as lifestyle modifications and adjuncts to pharmacotherapy. Amount of physical activity, tobacco use, and alcohol intake also were examined.
At the time of enrollment, 31% of the women reported taking estrogen, 24% took calcium supplementation, and 4% took vitamin D. Over the study period, the number of women taking bisphosphonates, calcitonin, and SERMs increased, and those reporting hormone therapy use decreased.
Appropriate osteoporosis medication use was reported more frequently in visits subsequent to diagnosis of osteoporosis only (31.7%) and diagnoses of both osteoporosis and fracture (29.4%), compared with diagnosis of fracture only (5.2%), when pharmacotherapies other than hormone therapy, calcium, and vitamin D were considered.
Even when hormone therapy was included as possible pharmacotherapy for osteoporosis in participants not receiving hormone therapy at baseline, the treatment rate increased from 21.6% to only 27.9%.
Other factors associated with significantly higher likelihood of osteoporosis pharmacotherapy were higher daily calcium intake, Asian or Pacific Islander race/ethnicity (compared with white/Caucasian), higher income, and hormone therapy use (past or present).
Less likely to use osteoporosis treatment were women with black/African-American race/ethnicity (compared with white/Caucasian), BMI at 30 or more (compared with BMI 18.5-24.9), current tobacco use (compared with past use or lifetime nonusers), and history of arthritis.
Calcium and vitamin D supplementation, behavior changes, and pharmacotherapy were suboptimal in postmenopausal women who reported an incident fracture or new diagnosis of osteoporosis during the study, in spite of well-established guidelines for fracture prevention, the authors concluded.
They observed statistically significant associations between pharmacotherapy for osteoporosis and baseline total calcium intake, prior osteoporosis diagnosis, fracture site, and smoking status, but did not find an association between osteoporosis pharmacotherapy and participants' age, education level, or insurance type.
"Our findings can inform future studies as well as development of interventions and education programs aimed toward improving treatment of osteoporosis and prevention of fractures, as well as awareness about subgroups of older women particularly vulnerable to suboptimal osteoporosis treatment and fracture prevention," the researchers suggested. "The potential translation to reduced morbidity and mortality has important public health relevance as the population ages, lives longer, and experiences greater cumulative exposure to factors detrimental to bone health."
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Disclosures
The Women's Health Initiative (WHI) program is funded by the National Heart, Lung, and Blood Institute, the NIH, and the U.S. Department of Health and Human Services.
Sattari and co-authors disclosed no relevant relationships with industry.
Primary Source
The American Journal of Medicine
Sattari M, et al "Osteoporosis in the Women's Health Initiative: Another treatment gap?" Am J Med 2017; DOI: 10.1016/j.amjmed.2017.02.042.