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Consider drug treatment in late-life women with osteoporosis

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Rethinking osteoporosis treatment for older patients

Older patients with osteoporosis with multimorbidities are the most at risk for hip fractures, which should place an emphasis on research into their treatment, Sarah D. Berry, MD, MPH; Sandra Shi, MD; and Douglas P. Kiel, MD, MPH, of Harvard Medical School, Boston, wrote in an invited commentary.

The coauthors noted that the study by Ensrud et al. is of “great clinical importance, given the ongoing recognition that clinical guidelines should consider multimorbidity.” Currently, the guidelines for treating osteoporosis do not consider age, comorbidities, or frailty, but this study indicates that older women can see benefits from treatment.

They also acknowledged the value of patient preference, referencing a study where 80% of older women “would prefer death as opposed to a hip fracture leading to institutionalization.” All in all, the work of Ensrud et al. is a reminder of “the dangers in ignoring the problem” and the need for future guidelines in osteoporosis treatment to address osteoporosis treatment for older patients with multimorbidity.

These comments are adapted from an invited commentary accompanying the article by Ensrud et al. (JAMA Intern Med. 2019 Jun 17. doi: 10.1001/jamainternmed.2019.0688 ). Dr. Berry reported receiving royalties from UpToDate outside the submitted work. Dr. Kiel reported receiving royalties from UpToDate, along with grants from the Dairy Council and Radius Health, and personal fees from Springer outside the submitted work. Dr. Shi reported no relevant financial disclosures. No funding for this editorial was reported.


 

FROM JAMA INTERNAL MEDICINE

Women in their 80s who have osteoporosis are at greater risk of fracture than their counterparts without the disease and therefore have more to gain from osteoporosis treatment, regardless of the presence of any comorbidities, according to a new study.

To determine how and when to treat older women for osteoporosis, Kristine E. Ensrud, MD, of the University of Minnesota, Minneapolis, and coauthors studied active surviving participants in the Study of Osteoporotic Fractures. The cohort comprised 1,528 women who met criteria for either osteoporosis (n = 761) or without osteoporosis but at high fracture risk (n = 767). Mean age at the time of examination was 84 years and mean femoral neck bone mineral density (BMD) T-score was −2.24.

During an average follow-up period of 4.4 years after initial examination, 125 women (9%) experienced a hip fracture and 287 (19%) died without experiencing that outcome. The 5-year absolute probability of mortality was 25% (95% confidence interval, 21.8%-28.1%) in women with osteoporosis and 19% (95% CI, 16.6%-22.3%) in women without osteoporosis but at high fracture risk. Although both groups saw mortality probability increase with more comorbidities and poorer prognosis, 5-year hip fracture probability was 13% (95% CI, 10.7%-15.5%) among women with osteoporosis and 4% (95% CI, 2.8%-5.6%) among women without osteoporosis but at high fracture risk.

An elderly woman takes pills Bojan89/iStock/Getty Images Plus

This probability of the women with osteoporosis experiencing a hip fracture, “even after considering their competing mortality risk” suggests that “initiation of drug treatment in late-life women with osteoporosis may still be effective in the prevention of subsequent hip fracture,” the researchers wrote in JAMA Internal Medicine.

Dr. Ensrud and associates acknowledged their study’s limitations, including the cohort being made up of community-dwelling white women and thus the results not being generalizable to men or women of other racial or ethnic groups. But the researchers noted that the mean femoral neck BMD of women in the study “was essentially identical to that of a nationally representative sample of community-dwelling women 80 years and older enrolled in the 2005 to 2008 NHANES [National Health and Nutrition Examination Survey].”

Dr. Cynthia M. Boyd reported receiving royalties from UpToDate and a grant from the National Institutes of Aging Dr. Katie L. Stone reported receiving grant support from Merck, and Dr. Lisa Langsetmo reported receiving grants from the National Institutes of Health and Merck. No other authors reported any relevant financial disclosures. The Study of Osteoporotic Fractures was supported by NIH and grants from NIA.

SOURCE: Ensrud KE et al. JAMA Intern Med. 2019 Jun 17. doi: 10.1001/jamainternmed.2019.0682.

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