Background Long term anti-resorptive therapy (usually in the form of bisphosphonates (BP)) is recognised as an effective anti-fracture therapy in patients with osteoporosis, particularly in patients at high risk of fracture. It has become increasingly apparent however that the longer-term use of such therapies can result in unusual but significant drug-related side effects such as osteonecrosis of the jaw (ONJ) and atypical fracture. In light of this, recent expert opinion has suggested the need to re-assess the continuing need for BP therapy on a patient-by-patient basis beyond 5 years of use
Objectives We perfomed a pilot audit to assess the number of long-term BP users in a typical GP setting who might require prescribing action taken following a medication review of the type suggested in this recent NOGG guidance.
Methods Ty Bryn Surgery in Caerphilly was selected for this pilot. GP EMIS software was employed. The system was interrogated to define the total number of patients receiving BP on repeat prescription, the length of existing therapy and diagnostic code (“osteoporosis”/osteopenia). Osteoporotic patients having received >5 yrs of BP therapy were identified and a notes audit undertaken to collect demographic details for National Osteoporosis Guideline Group (NOGG) assessment. These patients were mapped via the NOGG algorithm/advice to one of four potential outcomes (discontinue BP, re-assess via DEXA, re-evaluate or continue BP).
Results From a GP population base of 10,217, a total of 174 patients receiving therapy for low BMD were identified. Of these, 102 had a diagnosis of osteoporosis and 60 osteopenia. Due to time limitations, our study focussed only on the former group.In this group, 45 patients were identified as long-term (>5 yr) users and subject to notes review. Of these patients, sufficient data was available in n=40 to complete NOGG assessment. 39/40 patients were female. Mean age was 73 (range 54-90 yrs).
Drug use (where known) comprised alendronic acid in 27 patients, Risedronate in 3, Ibandronate in 8 and strontium therapy in 2. Mean length of BP Rx (in n=40) was 9.9 yrs (range 5-16 yrs). N=21/40 patients had suffered low trauma fracture (including hip fracture(s) in n=4 and vertebral fracture(s) in n=4 patients). 10/40 patients continued on oral steroid therapy (4 current; 6 previous) and 3/40 patients suffered from RA.
Reliable pre-treatment DEXA results were not available in n-17/40 patients. N=15 patients had confirmed osteoporotic pre-Rx T scores at L spine and n=17 at either hip.
Outcomes following NOGG guidance for BP patients supported a clinical decision to continue, discontinue, re-evaluate, re-assess via DEXA in n=17, 13, 4 and 4 patients respectively.
Conclusions Our pilot assessment of a single Welsh GP population base suggests that in such a setting a significant number of patients can be identified who continue on long-term BP therapy in primary care. Our application of NOGG guidance to this cohort suggests that a significant number of such patients (55%) should be considered for a medication review or re-assessment of the need for continuing therapy to reduce the incidence of uncommon but significant side-effects associated with longer-term BP use in Wales.
Disclosure of Interest None declared