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2019 HSR&D/QUERI National Conference Abstract

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4058 — Decision making related to use of pharmacological therapies of osteoporosis in Veterans with spinal cord injury and disorder

Lead/Presenter: Cara Ray,  COIN - Hines
All Authors: Ray CE (Center of Innovation for Complex Chronic Healthcare, Edward J. Hines, Jr. VA Hospital, Hines, IL; Department of Psychology, Loyola University Chicago), Le, B (Charlie Norwood Veterans Affairs Medical Center, Augusta, GA; Department of Medicine, Division of Rheumatology, Medical College of Georgia at Augusta University, Augusta, GA), Gonzalez, B (Center of Innovation for Complex Chronic Healthcare, Edward J. Hines, Jr. VA Hospital, Hines, IL; Feinberg School of Medicine, Northwestern University, Chicago, IL; Department of Biostatistics, University of Illinois, Chicago, IL; Department of Mathematics, Northeastern Illinois University, Chicago, IL) Miskevics, S (Center of Innovation for Complex Chronic Healthcare, Edward J. Hines, Jr. VA Hospital, Hines, IL) Weaver, FM (Center of Innovation for Complex Chronic Healthcare, Edward J. Hines, Jr. VA Hospital, Hines, IL; Public Health Sciences, Stritch School of Medicine, Loyola University, Maywood, IL) Priebe, M (Charlie Norwood Veterans Affairs Medical Center, Augusta, GA) Carbone, LD (Charlie Norwood Veterans Affairs Medical Center, Augusta, GA; Department of Medicine, Division of Rheumatology, Medical College of Georgia at Augusta University, Augusta, GA)

Objectives:
To understand the clinical decision-making underscoring the initiation and discontinuation of osteoporosis medications in SCI/D.

Methods:
Veterans with a SCI/D with at least one prescription for an osteoporosis medication (bisphosphonate, calcitonin, denosumab, raloxifene, teriparatide) who received healthcare within Veterans Affairs (VA) from 2005-2015 were identified using VA administrative databases. A 10% subsample of Veterans was selected for electronic health record (eHR) review.

Results:
267 Veterans with 330 prescriptions underwent eHR review. Of the 187 Veterans with prescriptions for prevention or treatment of osteoporosis, the primary reason for initiation was a finding of osteopenia or osteoporosis based on Dual Energy X-ray Absorptiometry (DXA) scan (n = 119, 63.6% of Veterans); primarily at the hip (81.0% of DXAs). The majority (77%) of DXAs were "screening tests," with SCI/D being the sole reason for the scan. Fractures (n = 51, 27.7%) and fall risk concerns (n = 29, 15.5%) were other major reasons for medication initiation. Bisphosphonates were the most frequently prescribed medication for osteoporosis (n = 223, 67.6%). On average, oral bisphosphonates were filled for < 3 years, with medication-related side effects (n = 23, 15.7% of bisphosphonates discontinued), predominately gastrointestinal (n = 13, 73.9%) as the most common reason for discontinuation. Drug holidays occurred in 14.2% of 35 oral bisphosphonates used for > 5 years. No cases of osteonecrosis of the jaw were found. There was one case of an atypical femoral fracture which could not be confirmed.

Implications:
The decision to initiate pharmacological therapies in SCI/D is primarily based on osteopenia or osteoporosis at the hip by screening DXAs. Gastrointestinal side effects are the major reason for discontinuation of oral bisphosphonates and use appears to be only short term.

Impacts:
Medications for osteoporosis have not been reported to reduce fracture rates in patients with spinal cord injury and disorders (SCI/D), yet these medications are still prescribed. Furthermore, there are no guidelines for routine DXA screening in SCI/D, yet a screening DXA was the most common reason for initiating a medication for osteoporosis. The reasons for discontinuation in the current study highlight the need for new therapies for osteoporosis in SCI/D.