Category: Federal Forum Posters
Purpose: Literature supports bisphosphonates use for the prevention of fractures in postmenopausal women with osteoporosis and men with osteoporosis. Specifically, patients that are diagnosed with osteoporosis receive the most benefit. Long-term utilization of bisphosphonate therapy has been associated with increased risk of side effects without additional benefit. Studies have found that utilization of bisphosphonate therapy for an extended duration does not lead to a statistically significant increase in clinical vertebral fractures, non-vertebral fractures, or clinical fractures.
Therefore, this MUE was conducted to assessed the appropriateness of active bisphosphonate therapy and recommendations to providers were made to deprescribe bisphosphonate therapy as appropriate.
Methods: This medication use evaluation was approved by Pharmacy and Therapeutics Committee. A patient list was generated from Microsoft SQL on 3/14/2018 that included all veterans in a rural VA healthcare system with an active bisphosphonate prescription issued between 3/14/2017 and 3/14/2018. Education was provided to pharmacists regarding appropriate use of bisphosphonate therapy. Patients were then distributed for retrospective chart reviews to pharmacists within this facility. Patient charts were accessed through the Computerized Patient Record System (CPRS). Veterans were excluded upon chart review if determined not to be taking a bisphosphonate. The following data were collected: age; sex; race; height; weight; prescriptions characteristics; calcium and vitamin D supplementation; bone mineral density; indication for use and documentation on cover sheet; labs including kidney function, liver function, calcium, vitamin D and TSH; history of fractures and side effects. Recommendations for continuation or discontinuation of bisphosphonate therapy, calcium and vitamin D supplementation and future monitoring was provided to prescribers via notes entered into patient charts.
Results: A majority of patients were receiving bisphosphonates for primary osteoporosis. Only 34.3 percent of patients have an indication for bisphosphonate therapy listed as an active problem. Bone mineral density data was available for review in 80 percent of patients receiving bisphosphonate therapy, however a follow up bone mineral density was recommended to be ordered at next follow up in 62.9 percent of patients. A majority of patient receiving bisphosphonate therapy are also receiving vitamin D supplementation (62.9 percent), however lacked calcium supplementation (65.7 percent). Additionally, pharmacists recommended initiating calcium supplementation in 62.9 percent of patients and initiating vitamin D supplementation in 37.1 percent of patients. One patient was not started on calcium supplementation due to history of kidney stones. Bisphosphonate therapy was deemed appropriate in 65.7 percent of patients at the start of therapy, 68.6 percent of patients currently on treatment and to continue in 60 percent of patients. Therefore the recommendation to stop bisphosphonate therapy was made in 31.4 percent of patients.
Conclusion: Continued assessment of active bisphosphonate therapy upon renewal is warranted. Encourage providers and pharmacists to assess bisphosphonate therapy upon renewal of bisphosphonate therapy to ensure the need for continued use. Utilization of clinical reminders to prompt providers to order updated bone mineral density scans could increase monitoring data and allow for monitoring of bisphosphonate therapy. Discourage the use of bisphosphonate therapy in patients that are inappropriate including those with osteopenia, poor renal function and low risk of fracture.
Taler Steir– Pharmacist, Sheridan VA Healthcare System, Sheridan, WY