Abstract
Summary
Antiresorptive treatment reduces the risk of fractures, but most patients remain at elevated risk. We used health registers to identify predictors of new major osteoporotic fractures in patients adhering to alendronate. Risk factors showed a different pattern than in the general population and included dementia, ulcer disease, and Parkinson’s disease.
Introduction
Antiresorptives reduce the excess risk of fractures in patients with osteoporosis, but most patients remain at elevated risk. In some countries, patients must sustain fractures while on bisphosphonate (BP) treatment to qualify for more expensive treatment. It is unclear if patients who fracture on BP can be viewed as a distinct subgroup.
Methods
The National Prescription registry was used to identify 38,088 new alendronate users. The outcome was major osteoporotic fractures 6+ months after filling the first prescription in patients with a medication possession ratio > 80 %.
Results
One thousand and seventy-two (5.5 %) patients sustained major osteoporotic fractures. The risk increased with age and was lower in men. The most important risk factor was the number of comedications (hazard ratio (HR) 1.04, 95 % CI 1.03–1.06, for each drug). Dementia (HR 1.81, 95 % CI 1.18–2.78), prior fracture (one: HR 1.17, 95 % CI 1.02–1.34; multiple: HR 1.34, 95 % CI 1.08–1.67), and ulcer disease (HR 1.45, 95 % CI 1.04–2.03) also increased the risk. Diabetes did not influence fracture risk, nor did rheumatic disorders. The risk was lower in glucocorticoid users (HR 0.78, 95 % CI 0.65–0.93).
Conclusion
Risk factors while adhering to BP show a somewhat different pattern than that of the general population and FRAX. Ulcer disease and dementia may impair the ability to use the medications correctly. Though this is an observational study and associations may not be causal, it may be prudent to include dementia, ulcer disease, and Parkinson’s disease to capture the risk of fractures on treatment. Lower risk in patients treated with glucocorticoids and in men probably reflects a lower treatment threshold related to guidelines.
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Conflicts of interest
B. Abrahamsen serves on advisory boards for Nycomed and Amgen and has received grant or research support from Novartis, Nycomed, Amgen, and Merck and speaker fees from Nycomed, Merck, Eli Lilly, and Amgen. KH Rubin has no disclosures. P. Eiken has received grant/research support from Nycomed, Amgen, and Novartis and is on Speakers Bureau with Nycomed, Novartis, GSK, and Eli Lilly. R. Eastell serves as a consultant, has received honoraria for speaking, and has received grant support from Amgen, AstraZeneca, California Pacific Medical Center, GlaxoSmithKline, Hologic, Kyphon Inc., Lilly Industries, Maxygen, Nastech Pharmaceuticals, Nestle Research Center, New Zealand Milk Limited, Novartis, Novo Nordisk, ONOPharma, Organon Laboratories, Osteologix, Pfizer, Procter & Gamble Pharmaceuticals, Roche Diagnostics, Sanofi-Aventis, Servier, Shire, Tethys, Trans-Pharma Medical Limited, Unilever, and Unipath. This study did not receive outside funding.
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Abrahamsen, B., Rubin, K.H., Eiken, P.A. et al. Characteristics of patients who suffer major osteoporotic fractures despite adhering to alendronate treatment: a National Prescription registry study. Osteoporos Int 24, 321–328 (2013). https://doi.org/10.1007/s00198-012-2184-6
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DOI: https://doi.org/10.1007/s00198-012-2184-6