Outcome of osteoporosis evaluation, treatment, and follow-up in patients referred to a specialized outpatient clinic compared to patients in care of general practitioners.

In Denmark, osteoporosis treatment is either handled by general practitioners or at more resource demanding specialist clinics. We evaluated the treatment adherence and persistence in the two settings, which were overall similar. The type of medical support did, however, differ and was provided to two very different patient populations. PURPOSE: The study aimed to investigate the effect of patient care by general practitioners (GPs) or specialists on treatment adherence among osteoporosis patients initiating treatment with oral bisphosphonates (OB). METHODS: Dual-energy X-ray absorption (DXA)-scanning data from 2005 to 2013 were extracted. Treatment naïve patients with a T-score ≤ - 2.5 (spine or hip) were included. Information on medical treatment, comorbidities, and socio-economic status was extracted from Danish registries. Scanning results were evaluated by a specialist. Subsequent treatment initiation and follow-up was either handled by GPs or specialists: GP population (GPP) vs. specialist population (SP). Primary adherence was defined as treatment initiating within 12 months from diagnosis and secondary adherence as days with medicine possession rates (MPR) > 80%. RESULTS: Of 11,201 DXA-scanned patients, 3685 met the inclusion criteria (GPP = 2177, SP = 1508). The GPP consisted of relatively more men, was older, had shorter education, lower income, and more comorbidities. There was no difference in baseline T-score or prior incidence of major osteoporotic fractures (MOFs). The GPP was primarily treated with OB and had better primary adherence (adjusted ORGPP/SP = 1.52 [1.31-1.75], p < 0.0001) than the SP that to a higher degree received another treatment. Secondary adherence was similar (adjusted ORGPP/SP: OR12 months = 1.02 [0.83-1.26]; OR24 months = 0.90 [0.73-1.10]; OR4 years = 0.88 [0.71-1.07]; OR5 years = 0.91 [0.74-1.13]. CONCLUSION: Patients in care of specialists were most likely to receive a treatment other than OB. Primary adherence was highest in the GPP, whereas short- and long-term persistence was similar for up to 5 years whether treated by a specialist or a GP.

Hepatotoxicity during 6-thioguanine treatment in inflammatory bowel disease and childhood acute lymphoblastic leukaemia: A systematic review.

BACKGROUND: The recently established association between higher levels of DNA-incorporated thioguanine nucleotides and lower relapse risk in childhood acute lymphoblastic leukaemia (ALL) calls for reassessment of prolonged 6-thioguanine (6TG) treatment, while avoiding the risk of hepatotoxicity. OBJECTIVES: To assess the incidence of hepatotoxicity in patients treated with 6TG, and to explore if a safe dose of continuous 6TG can be established. DATA SOURCES: Databases, conference proceedings, and reference lists of included studies were systematically searched for 6TG and synonyms from 1998-2018. METHODS: We included studies of patients with ALL or inflammatory bowel disorder (IBD) treated with 6TG, excluding studies with 6TG as part of an intensive chemotherapy regimen. We uploaded a protocol to PROSPERO (registration number CRD42018089424). Database and manual searches yielded 1823 unique records. Of these, 395 full-texts were screened for eligibility. Finally, 134 reports representing 42 studies were included. RESULTS AND CONCLUSIONS: We included data from 42 studies of ALL and IBD patients; four randomised controlled trials (RCTs) including 3,993 patients, 20 observational studies including 796 patients, and 18 case reports including 60 patients. Hepatotoxicity in the form of sinusoidal obstruction syndrome (SOS) occurred in 9-25% of the ALL patients in two of the four included RCTs using 6TG doses of 40-60 mg/m2/day, and long-term hepatotoxicity in the form of nodular regenerative hyperplasia (NRH) was reported in 2.5%. In IBD patients treated with 6TG doses of approximately 23 mg/m2/day, NRH occurred in 14% of patients. At a 6TG dose of approximately 12 mg/m2/day, NRH was reported in 6% of IBD patients, which is similar to the background incidence. According to this review, doses at or below 12 mg/m2/day are rarely associated with notable hepatotoxicity and can probably be considered safe.