Given the expected increase in the number of patients with osteoporosis and fragility fractures it is important to have concise information on trends in prescription rates of anti-osteoporosis drugs ...(AOD).
We undertook a retrospective observational study using the UK Clinical Practice Research Datalink (CPRD) in the UK between 1990 and 2012 in subjects 50years or older, stratified by age, sex, geographic region and ethnicity. Yearly prescription incidence rates of any AOD and of each specific AOD were calculated as the number of patients first prescribed these AODs per 10,000person-years (py).
In women, yearly rates of first prescription of any AOD increased from 1990 to 2006 (from 2.3 to 169.7 per 10,000py), followed by a plateau and a 12% decrease in the last three years. In men, a less steep increase from 1990 to 2007 (from 1.4 to 45.3 per 10,000py) was followed by a plateau from 2008 onwards. Yearly rates of first prescription of any AOD increased up to the age of 85–89years (248.9 per 10,000py in women and 119.3 in men). There were marked differences between ethnic groups and regions. Bisphosphonates were the most frequently prescribed AODs: etidronate till 2000, and then subsequently alendronate.
We have demonstrated marked secular changes in rates of anti-osteoporosis drug prescription over the last two decades. The plateau (and decrease amongst women) in rates in recent years, set against an ever ageing population, is worrying, suggesting that the well-documented care gap in osteoporosis treatment persists. The differences in prescription rates by geographic location and ethnicity raise intriguing questions in relation to underlying fracture rates, provision of care and health behaviour.
We studied the prescription incidence of anti-osteoporosis drugs (AOD) from 1990 to 2012 in the UK CPRD. Overall AOD prescription incidence showed a strong increase from 1990 to 2006, followed by a plateau in both sexes and a decrease amongst women in the last three years.
•In UK CPRD we documented rates of anti-osteoporosis treatment by age, sex, ethnicity, geographic location and calendar time.•In women, annual rates of first prescription increased from 1990-2006 followed by a plateau and a 12% decrease 2009-2012.•In men, prescription rates increased less steeply from 1990-2007 and then levelled from 2008 onwards.•There were marked differences in anti-osteoporosis treatment rates by ethnicity and geographic location within the UK.
Summary
We studied sex-specific incidence rates in a population 50 years or older in the UK. In the period of 1990–2012, the overall rate of fracture did not change, but there were marked secular ...alterations in the rates of individual fracture types, particularly hip and spine fractures in the elderly.
Introduction
There is increasing evidence of secular changes in age- and sex- adjusted fracture incidence globally. Such observations broadly suggest decreasing rates in developed countries and increasing rates in transitioning populations. Since altered fracture rates have major implications for healthcare provision and planning, we investigated secular changes to age- and sex-adjusted fracture risk amongst the UK population aged 50 years or above from 1990 till 2012.
Methods
We undertook a retrospective observational study using the Clinical Practice Research Datalink (CPRD), which contains the health records of 6.9 % of the UK population. Site-specific fracture incidence was calculated by calendar year for men and women separately, with fracture type categorised according to ICD-9 classification. Linear regression analysis was used to calculate mean annualised change in absolute incidence. For presentational purposes, mean rates in the first 5 years and last 5 years of the period were calculated.
Results
Overall fracture incidence was unchanged in both women and men from 1990 to 2012. The incidence of hip fracture remained stable amongst women (1990–1994 33.8 per 10,000 py; 2008–2012 33.5 per 10,000 py;
p
trend annualised change in incidence = 0.80) but rose in men across the same period (10.8 to 13.4 per 10,000 py;
p
= 0.002). Clinical vertebral fractures became more common in women (8.9 to 11.8 per 10,000 py;
p
= 0.005) but remained comparable in men (4.6 to 5.9 per 10,000 py;
p
= 0.72). Similarly, the frequency of radius/ulna fractures did not change in men (9.6 to 9.6 per 10,000 py;
p
= 0.25), but, in contrast, became less frequent in women (50.4 to 41.2 per 10,000 py;
p
= 0.001). Secular trends amongst fractures of the carpus, scapula, humerus, foot, pelvis, skull, clavicle, ankle, patella, and ribs varied according to fracture site and sex.
Conclusion
Although overall sex-specific fracture incidence in the UK population 50 years or over appears to have remained stable over the last two decades, there have been noticeable changes in rates of individual fracture types. Given that the impact of a fracture on morbidity, mortality, and health economy varies according to fracture site, these data inform the provision of healthcare services in the UK and elsewhere.
The use of proton pump inhibitors (PPIs) has been associated with an increased fracture risk in observational studies. However, the reported association between PPI use and bone mineral density ...(BMD), bone microarchitecture, and bone strength is inconsistent. This study aims to assess the association between PPI use and bone microarchitecture and strength using high-resolution peripheral quantitative CT (HR-pQCT) in a three-year follow-up study in patients with a recent fracture visiting the Fracture Liaison Service (FLS).
This three-year prospective cohort study included FLS patients aged ≥ 50 years with a recent fracture (median age 62 IQR 56–69 years, 68.7 % females) and without anti-osteoporosis treatment indication. HR-pQCT scans (distal radius and tibia) were obtained at baseline (T0) and three-year follow-up (T3). Volumetric bone mineral density and bone area, microarchitecture, and strength (micro-finite element analysis) were determined. The association between three-year continuous PPI use and the percentage change in HR-pQCT parameters between T0 and T3 was assessed using sex-stratified multivariate linear regression analyses. Covariates included age, BMI, vitamin-D deficiency (< 50 nmol/l), glucocorticoid use, and cardiovascular co-morbidity (males and females) fracture type (major/hip vs. all others, only males) and probable sarcopenia (only females).
In total, 282 participants had available medication data throughout follow-up, of whom 20.6 % were continuous PPI users. In both males and females with complete HR-pQCT follow-up data (males: N = 69 radius, N = 84 tibia; females: N = 147 radius, N = 168 tibia), PPI use was not associated with the percentage change of any of the bone microarchitecture or strength parameters between T0 and T3 at the radius and tibia as compared to non-use.
Compared to non-use, PPI use was not associated with the change of bone microarchitecture and strength in FLS patients at three years of follow-up. These results do not support that an altered bone microarchitecture or strength may contribute to the increased fracture risk associated with PPI use, as reported in observational studies.
•We assessed the association between PPI use and bone microarchitecture and strength.•The association was assessed in a three-year prospective follow-up study of FLS patients.•Included were 282 patients with a recent fracture, of which 20 % PPI users.•PPI use was not associated with the three-year change in bone microarchitecture and strength.•The results do not support the previously reported increased fracture risk in PPI users.
Summary
Impaired physical performance is associated with increased fracture risk. Performance on four physical functioning tests and prevalence of sarcopenia were assessed for 1789 fracture patients ...and compared to reference data. Performance was low on all tests, especially for patients with a hip, major or ≥ 1 prevalent vertebral fracture.
Purpose Introduction
Impaired physical performance and sarcopenia are associated with increased fracture risk. This study aims to assess physical performance and the prevalence of sarcopenia in patients with a recent clinical fracture attending the Fracture Liaison Service (FLS) compared to population means.
Methods
In this cross-sectional study, chair stand test (CST), handgrip strength (HGS), timed-up-and-go (TUG), 6-min walking-test (6MWT), and sarcopenia (following EWGSOP2) were assessed. The proportion of patients with impaired/poor performance compared to reference data was calculated (Z-score: ≥ − 2SD to < − 1 (impaired) and < − 2 SD (poor)). Associations of fracture type, sex, age, and time since fracture with Z-scores were assessed using linear regression analyses.
Results
A total of 1789 consecutive FLS patients were included (median age (IQR): 66 (59–74), 70.7% females, 3.9 (± 1.6) months after fracture). The prevalence of impaired/poor performance for CST, HGS, TUG, and 6MWT was 39.2%, 30.4%, 21.9%, and 71.5%, respectively (expected proportion of 16%) and 2.8% had sarcopenia. Lower Z-scores (
P
< 0.001) were found for hip, major, and ≥ 1 prevalent vertebral fracture (VF) in CST (major: regression coefficient (
B
) (95%CI) = − 0.25 − 0.34, − 0.16; hip:
B
= − 0.32 − 0.47, − 0.17, VF:
B
= − 0.22 − 0.34, − 0.11), TUG; (major:
B
= − 0.54 − 0.75, − 0.33; hip:
B
= − 1.72 − 2.08, -1.35, VF:
B
= − 0.61 − 0.88, − 0.57), 6MWT (major:
B
= − 0.34 − 0.47, − 0.21; hip:
B
= − 0.99 − 1,22, − 0.77, VF:
B
= − 0.36 − 0.53, − 0.19).
Conclusions
Physical performance is significantly lower in FLS patients compared to healthy peers, especially in patients with hip, major or prevalent VF. These findings underline the need to assess and improve the physical performance of FLS patients, despite a low prevalence of sarcopenia.
Summary
In this cross-sectional study, two-thirds of Fracture Liaison Service (FLS) patients had comorbidities and medications associated with increased bone- or fall-related fracture risk. ...Bone-related and fall-related fracture risk (BRR and FRR) were associated with age and fracture type, but not with gender or BMD. Systematic evaluation of these factors leads to a more profound assessment in FLS care.
Introduction
This study is a systematic evaluation of comorbidities and medications associated with increased fracture risk in patients aged 50–90 years with a recent fracture visiting the FLS.
Methods
In this cross-sectional cohort study, comorbidities were classified according to ICD-10 and medications according to the Anatomic Therapeutic Chemical (ATC) classification and further categorized into those associated BRR and FRR.
Results
Of 1282 patients (72% women; 65 ± 9 years), 53% had at least one BRR, 46% had at least one FRR, and 66% at least one BRR and/or FRR. At least one BRR, as well as at least one FRR were associated with age, BMI, and fracture type, but not with gender or BMD. The proportion of patients with only BRR (± 20%) or only FRR (± 10%) was similar among ages, gender, BMI, fracture type, and BMD. The combination of at least one BRR and at least one FRR was significantly associated with age, BMI, and major fractures, but not with gender or BMD.
Conclusion
Comorbidities and medications associated with increased fracture risk are present in two-thirds of patients visiting the FLS. In addition, the proportion of patients having a combination of BRR and FRR increased significantly with age, BMI, and fracture severity. This indicates that systematic evaluation of these factors is important for a more profound assessment of subsequent fracture risk in FLS care.
Summary
We evaluated the association between prevalent vertebral fractures and bone micro-architecture and strength measured using HR-pQCT in postmenopausal women with a recent non-vertebral fracture ...visiting the Fracture Liaison Service. The presence and severity of prevalent vertebral fracture reflect generalized bone deterioration.
Introduction
We evaluated the association between prevalent vertebral fractures (VFs) and bone micro-architecture and strength measured using HR-pQCT in postmenopausal women visiting the Fracture Liaison Service.
Methods
In this cross-sectional study in women aged 50–90 with a recent non-vertebral fracture (NVF), VFs were identified on lateral spine images by dual-energy X-ray absorptiometry. Bone micro-architecture and strength were measured at the non-dominant distal radius and distal tibia using HR-pQCT. Linear regression analyses were used to estimate the association between prevalent VFs and HR-pQCT parameters.
Results
We included 338 women of whom 74 (21.9%) women had at least one prevalent VF. After adjustment for femoral neck aBMD (FN aBMD) and other parameters, women with at least one prevalent vertebral fracture had significantly lower total and trabecular vBMD and trabecular number (
β
− 16.7, − 11.8, and − 7.8 in the radius and − 21.4, − 16.6, and − 7.2 in the tibia, respectively), higher trabecular separation at the radius and tibia (
β
9.0 and 9.3, respectively), and lower cortical thickness and calculated ultimate failure load and compressive bone strength at the tibia (
β
− 5.9, − 0.6, and − 10.9, respectively) as compared with those without prevalent VFs. Furthermore, more severe prevalent VFs were associated with even lower total and trabecular vBMD and lower ultimate failure load and compressive stiffness at the radius and tibia, and lower trabecular number and higher trabecular separation at the radius.
Conclusion
This study indicates that the presence and severity of prevalent VFs reflect generalized bone deterioration in women with a recent NVF, independently of FN aBMD.
Summary
We evaluated the impact of a new Dutch guideline on systematic implementation of densitometric Vertebral Fracture Assessment (VFA) in patients with a recent non-vertebral fracture. Systematic ...implementation resulted in a significant increase of VFA, diagnosis of vertebral fractures (VFs), and percentage of patients eligible for treatment.
Introduction
VFs are underdiagnosed although they are important predictors of fracture risk, independent of age and bone mineral density (BMD). The Dutch guideline on osteoporosis and fracture prevention recommends VFA in all patients aged >50 years with a recent non-VF. Our aim was to evaluate the effect of systematic implementation of densitometric VFA in patients with a recent non-VF at the fracture liaison service (FLS).
Methods
VFA was performed on lateral images of the spine using dual-energy X-ray absorptiometry (DXA) and graded according to Genant using Spine Analyzer software.
Results
We evaluated 582 patients before and 484 after implementation (mean age 67 and 66 years; 71 and 74% women, respectively). Performing VFA increased from 4.6 to 97.1% (
p
< 0.001) and the diagnosis of VFs from 2.2 to 26.2% for grade ≥ 1 (
p
< 0.001) and from 0.9 to 14.7% for grade ≥ 2 (
p
< 0.001). Prevalence of VFs increased with age (5.2% in 50–59-year olds to 27.8% in 80+-year olds,
p
< 0.001), but was similar for both genders, non-VF locations, and BMD. Including patients with osteopenia and a VF increased the percentage of patients eligible for treatment by a quarter, from 31.0% in the pre-guideline to 38.4% in the post-guideline cohort.
Conclusions
Systematic guideline implementation resulted in a significant increase of VFA, diagnosis of VFs, and percentage of patients eligible for treatment. VFA contributes to documenting the high prevalence of VFs in patients visiting the FLS with a non-VF in both genders, at any age, non-VF location, and BMD.
Introduction
The aim of this study was to investigate the associations of patient characteristics, bone mineral density (BMD), bone microarchitecture and calculated bone strength with secondary ...displacement of a DRF based on radiographic alignment parameters.
Materials and methods
Dorsal angulation, radial inclination and ulnar variance were assessed on conventional radiographs of a cohort of 251 patients, 38 men and 213 women, to determine the anatomic position of the DRF at presentation (primary position) and during follow-up.
Secondary fracture displacement was assessed in the non-operatively treated patients (
N
= 154) with an acceptable position, preceded (
N
= 97) or not preceded (
N
= 57) by primary reduction (baseline position). Additionally, bone microarchitecture and calculated bone strength at the contralateral distal radius and tibia were assessed by HR-pQCT in a subset of, respectively, 63 and 71 patients.
Outcome
Characteristics of patients with and without secondary fracture displacement did not differ. In the model with adjustment for primary reduction OR 22.00 (2.27–212.86),
p
= 0.008, total OR 0.16 (95% CI 0.04–0.68),
p
= 0.013 and cortical OR 0.19 (95% CI 0.05–0.80,
p
= 0.024 volumetric BMD (vBMD) and cortical thickness OR 0.13 (95% CI 0.02–0.74),
p
= 0.021 at the distal radius were associated with secondary DRF displacement. No associations were found for other patient characteristics, such as age gender, BMD or prevalent vertebral fractures.
Conclusions
In conclusion, our study indicates that besides primary reduction, cortical bone quality may be important for the risk of secondary displacement of DRFs.
Summary
We studied the incidence of subsequent fractures in persons of 50+ years from 1990 to 2012 and the relative risk (RR) of subsequent fractures after an index femur/hip fracture, stratified per ...5-year age band. Patients suffering a fracture have a high incidence of a subsequent fracture; the RR of subsequent fracture after a femur/hip fracture ranged from 2 to 7.
Introduction
Recent information on the risk of subsequent fractures after a broad range of index fractures in the UK population is scarce. We therefore studied the rates of subsequent fractures of the femur/hip, humerus, radius/ulna, vertebrae, rib, or pelvis after fractures at one of these sites from 1990 to 2012 in 3,156,347 UK men and women aged 50 years or over.
Methods
We undertook a retrospective observational study using the UK Clinical Practice Research Datalink (CPRD). The incidence of subsequent fractures at a specific site was calculated by dividing the observed number of fractures by the number of person-years (py) at risk. The relative risk (RR) of subsequent fractures after a femur/hip fracture, by 5-year age band, was calculated by dividing the incidence of a specific subsequent fracture type by the incidence of first fractures at the same site in the same age group.
Results
The highest subsequent fracture incidence after a femur/hip fracture was for humerus fracture in men (59.5/10.000 py) and radius/ulna fracture in women (117.2/10.000 py). After an index fracture of the radius/ulna, humerus fracture in men (59.3/10.000 py) and femur/hip fracture in women (82.4 per 10.000 py) were most frequent. The RR of fractures after a femur/hip fracture ranged from 2 to 7 and were highest in men and younger age groups.
Conclusion
Patients suffering a fracture have a high incidence of a subsequent fracture. Our findings demonstrate the importance of fracture prevention in patients with a history of a fracture by adequate medical diagnosis and treatment.
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