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Effect of Bisphosphonates on Fracture Outcomes Among Frail Older Adults

Andrew R Zullo^1,2, Tingting Zhang¹, Yoojin Lee¹

¹Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.

Journal of the American Geriatrics Society

|December 22, 2018

Abstract

Background:

Bisphosphonates are seldom used in frail, older adults, in part due to lack of direct evidence of efficacy in this population and increasing concerns about safety.

Objective:

We estimated the effects of bisphosphonates on hip fractures, nonvertebral fractures, and severe esophagitis among frail, older adults.

Design:

Population-based retrospective cohort using 2008 to 2013 linked national Minimum Data Set assessments; Online Survey Certification and Reporting System records; and Medicare claims.

Setting:

US nursing homes (NHs).

Participants:

Long-stay NH residents 65 years and older without recent osteoporosis medication use (N = 24,571). Bisphosphonate initiators were 1:1 propensity score matched to calcitonin initiators (active comparator).

Measurements:

Hospitalized hip fracture, nonvertebral fracture, and esophagitis outcomes were measured using part A claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated, controlling for over 100 baseline characteristics.

Results:

The matched cohort included 5209 new bisphosphonate users and an equal number of calcitonin users (mean age [SD] = 85 [8] years; 87% female; 52% moderate-severe cognitive impairment). Over a mean follow-up of 2.5 (SD = 1.7) years, 568 residents (5.5%) had a hip fracture, 874 (8.4%) had a nonvertebral fracture, and 199 (1.9%) had a hospitalized esophagitis event. Users of bisphosphonates were less likely than calcitonin users to experience hip fracture (HR = 0.83; 95% CI = 0.71-0.98), with an average gain in time without fracture of 28.4 days (95% CI = 6.0-50.8 days). Bisphosphonate and calcitonin users had similar rates of nonvertebral fracture (HR = 0.91; 95% CI = 0.80-1.03) and esophagitis events (HR = 1.11; 95% CI = 0.84-1.47). The effects of bisphosphonates on fractures and esophagitis were generally homogeneous across subgroups, including those defined by age, sex, history of prior fracture, and baseline fracture risk.

Conclusions:

Use of bisphosphonates is associated with a meaningful reduction in hip fracture among frail, older adults, but little difference in nonvertebral fracture or severe esophagitis. J Am Geriatr Soc 67:768-776, 2019.

Keywords:

Medicare bisphosphonates hip fracture nonvertebral fracture nursing homes

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