Patients with advanced kidney disease less likely to be treated for osteoporosis
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A study of provider prescribing patterns revealed patients with advanced chronic kidney disease, especially those on dialysis, had lower rates of osteoporosis treatment than patients with earlier stages of kidney disease.
The study, published in Kidney Medicine, included patients aged 55 years or older who were treated at Massachusetts General Hospital with an osteoporotic T-score of -2.5 or less at one or more skeletal sites.
“Pharmacological strategies to prevent fractures in the general population with osteoporosis include calcium, vitamin D, antiresorptive agents and bone anabolic drugs. In patients with chronic kidney disease (CKD) stages 2 [to] 3, post hoc analyses suggest that bisphosphonates, raloxifene, denosumab, or teriparatide may be effective for fracture prevention. However, there is limited published experience with these medications in patients with CKD stages 4 [to] 5,” Ignacio A. Portales-Castillo, MD, of Massachusetts General Hospital, Harvard Medical School, and colleagues wrote. “For these patients, experts suggest evaluating bone turnover by serologic markers, and to consider antiresorptive agents for those with evidence of normal or high turnover disease. Providers treating patients with CKD stages 4 [to] 5 and osteoporosis must balance the potential benefit of available pharmacologic options in fracture prevention against the largely unstudied potential side effects in this patient population.”
To compare current pharmacological treatment patterns between patients at varying stages of kidney disease, Portales-Castillo and colleagues matched those with CKD stages 4 to 5 patients to those with CKD stages 2 to 3 based on age, sex, race and year of DXA scan (osteoporosis was diagnosed based on DXA scan). Use of osteoporosis medication at 1 year and the incidence of fractures at 2 years after DXA were considered, with researchers defining the primary study outcome as the proportion of patients within each kidney disease group who were prescribed antiresorptive or bone anabolic medications.
Findings revealed that patients with CKD stages 4 to 5 had lower rates of osteoporosis treatment than those with CKD stages 2 to 3, with researchers determining 53% of the former group were prescribed an antiresorptive or anabolic medication compared with 71% of patients in the latter. This lower likelihood of receiving osteoporosis management for patients with advanced CKD occurred, according to the researchers, despite that these patients also had lower femoral bone density.
Findings also indicated that while treatment rates for patients with CKD stages 4 to 5 who were not on dialysis were statistically similar to patients with CKD stages 2 to 3 (60% vs. 71%), treatment rates for patients with CKD stage 5 on dialysis were “much lower” (36% vs. 71%).
Regarding patient outcomes, researchers observed fractures at 2 years were more common among patients with CKD stages 4 to 5 compared with those who had CKD stages 2 to 3 (11% vs. 23%).
Finally, Portales-Castillo and colleagues noted that 47% of patients with stages 4 to 5 CKD who were using antiresorptive medications had parathyroid hormone (PTH) levels lower than 100 pg/mL, which they contended demonstrates providers may be unclear as to the specific etiology of bone abnormalities in these patients (patients with CKD stages 4 to 5 were most commonly prescribed 35 mg per week of alendronate, while patients with CKD stages 2 to 3 were most commonly prescribed 70 mg per week).
“Hesitancy when prescribing antiresorptive medicines could be due to the perceived risk of worsening adynamic bone disease,” Portales-Castillo and colleagues wrote. “Nevertheless, the finding that 47% of patients using antiresorptive medications with stages 4 [to] 5 CKD had PTH levels lower than 100 pg/mL, which can potentially indicate adynamic bone disease in CKD, reveals that some CKD patients are treated without specific knowledge of the etiology of bone abnormalities in this population.
This study highlights knowledge gaps and practice variability regarding the use of osteoporosis medications in this high-risk population.”
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