Evaluating the Evidence Behind Treating Osteoporosis in the Oldest Adults.

OBJECTIVE: To review clinical trial data supporting the use of drugs to treat osteoporosis in the oldest adults, 74 years of age and older. DATA SOURCES: The PubMed database (September 1969-June 2017) was searched utilizing the following Medical Subject Headings terms: osteoporosis, postmenopausal, aged, 80 and over, and fractures, bone, in combination with diphosphonates, denosumab, parathyroid hormone, raloxifene, and calcitonin. STUDY SELECTION/DATA EXTRACTION: An initial search revealed 119 results, of which 18 clinical trials were included. Studies were selected that featured a randomized controlled design, fractures reported as a key outcome, and included subjects within the desired age range. DATA SYNTHESIS: Osteoporosis is common among older adults, and with an increasingly aging population, it will be imperative to know how to best manage this condition. Sparse clinical evidence exists for the impact of osteoporosis treatments in the given age range, and no clinical trials have exclusively looked at this age group as the primary target. CONCLUSION: Studies that included participants in this age group were found for alendronate, risedronate, zoledronic acid, denosumab, teriparatide, and abaloparatide. Efficacy appears to be maintained with advancing age for alendronate, zoledronic acid, denosumab, and teriparatide as demonstrated by post hoc analyses of pivotal trials. Alendronate has only demonstrated benefit in patients with previous vertebral fractures because of the study design of the trial. Abaloparatide showed improvement with treatment in the overall population, but age-specific analyses have not been published at this time.

An EHR-based method to structure, standardize, and automate clinical documentation tasks for pharmacists to generate extractable outcomes.

As the recognition of team-based care grows and pharmacists increase in patient care interventions, it is important that tools to track clinical services are easily accessible and well-integrated into workflow for all providers. We describe and discuss feasibility and implementation of data tools in an electronic health record to evaluate a pragmatic clinical pharmacy intervention focused on deprescribing in aged adults delivered at multiple clinical sites in a large academic health system. Of the data tools utilized, we were able to demonstrate clear documentation frequency of certain phrases during the intervention period for 574 patients receiving opioids and 537 patients receiving benzodiazepines. Although clinical decision support and documentation tools exist, they are underutilized or cumbersome to integrate into primary health care and strategies, such as employed, are a solution. This communication incorporates the importance of clinical pharmacy information systems in research design.

Fracture risk associated with common medications used in treating type 2 diabetes mellitus.

PURPOSE: Published data on the risk of bone fractures associated with medications used for the treatment of type 2 diabetes mellitus are summarized. SUMMARY: A systematic literature search identified 108 publications on controlled trials and 6 meta-analyses addressing the potential for fractures with the use of 7 commonly used antidiabetic classes: thiazolidinediones (TZDs), sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, biguanides, insulin, and sulfonylureas. Among all the classes of agents evaluated, only TZDs have been clearly linked to significantly increased fracture risk (number needed to harm [NNH], 99 in one meta-analysis and 172 in another meta-analysis) and only in female patients. Interim data from an ongoing large placebo-controlled trial suggest that use of the SGLT2 inhibitor canagliflozin may be associated with an elevated rate of fractures (absolute risk increase, 1.4%; NNH, 71) and decreased total-hip bone mineral density. Published data regarding the other evaluated classes of agents generally show no effect on fracture risk; some evidence suggests a small bone-protective effect with the use of DPP-4 inhibitors. CONCLUSION: In patients with type 2 diabetes mellitus, evidence is strongest that, among antidiabetic drugs, TZDs increase the risk of bone fractures; thus, TZDs should be used with caution in women. Canagliflozin is the only SGLT2 inhibitor linked to an increased fracture rate. Metformin, sulfonylureas, insulin, DPP-4 inhibitors, and GLP-1 agonists appear to have overall neutral effects on bone fractures.