Nessa Fallon

229Review on Teriparatide (Forsteo) Treatment on Older Patient Attending Bone Health Clinic in St. James’s Hospital

Background: Teriparatide (Forsteo) is an anabolic agent used in treatment of osteoporotic patients with high risk of vertebral fracture. It has been shown to reduce the risk of moderate to severe vertebral fractures by up to 80–90%. Vertebral fractures due to osteoporosis are common in older women. Methods: We aimed to identify the characteristics of older adults receiving teriparatide therapy at our bone health service. We also aimed to evaluate the effect of treatment with teriparatide on bone mineral density (BMD) as well as persistence with therapy. Data were obtained from our bone health service for all adults aged 70 or older who were treated with teriparatide for at least 18 months. Data included age, gender, baseline BMD and T scores as well as changes same with treatment. We dichotomised patients by age (70–79) and (≥80 + ) to evaluate for differences in the ‘older’ old. Results: Data for 250 patients were initially available but 20% did not persist with therapy leaving 198 in our analysis, 98 aged between 70–79 and 100 aged 80 or older. Overall 95% of those were female and approximately 60% had vertebral fractures in both groups. Mean T scores were between −3.5 to −3.6 (spine) and −2.7 at hip.There was significant increase in BMD of spine of 15.3% for aged ≥ 80 + and 13.3% in those aged 70–79 with P value < 0.05. While BMD at hip increased by 1.9 to 2.4%. Conclusions: Teriparatide was as effective at increasing BMD of spine in both age groups (70–79) as well as (≥80+). Our findings support using teriparatide in older adults including the ‘oldest old’ who have high risk of vertebral fractures and where benefit may be greatest.

155Adherence and Persistence to Teriparatide Treatment

Background: Osteoporosis increases the risk of fracture and associated morbidity and mortality. Efficacy of anti-osteoporotic treatment is based on drug potency and adherence and persistence. Teriparatide (TPTD) is the first anabolic agent developed for the treatment of osteoporosis and can significantly reduce the incidence of vertebral fractures. We evaluated adherence and persistence to TPTD treatment in patients with severe osteoporosis in a specialised Bone Health Service. Methods: A cross-sectional and retrospective longitudinal study was performed of all patients in our clinic with severe osteoporosis treated with TPTD from 2004 to 2016. Results: 597 patients commenced TPTD from 2004 to 2016: 90% female, mean age 70 years (range 30–99); 225 (38%) had vertebral fractures; 136 (23%) had Colles fractures; and 75 (13%) had a hip fracture. 106 patients (18%) are currently on treatment. 491 (82%) are no longer on treatment with 367 (75%) having completed 18 months or more of treatment. 122 patients (25%) stopped treatment before 18 months. Of these, the mean length of time on treatment was 195 days. Reasons for prematurely stopping included self-discontinued 19 (16%), side effects 62 (51%), death from any cause 8 (7%), incidental cancer diagnosis 4 (3%), lost to follow up 8 (7%) and other 21 (17%). Most side effects experienced were mild and included rash 4 (6%), palpitations 4 (6%), headaches 6 (10%), fatigue 7 (11%), nausea 11 (18%), dizziness 12 (19%) and generalised/ joint pain 29 (47%). However a small number reported night sweats 1 (2%), UTI/kidney stones 3 (5%) and weight loss 1 (2%). Conclusion: In our study adherence and persistence with TPTD was higher than that reported with oral antiresorptive treatments. The major factor that reduced adherence and persistence was tolerability. These findings are important, as high adherence and persistence with therapy is necessary to ensure an optimal therapeutic outcome.

238Hyperparathyroidism: How Much do Calcium and Vitamin D Matter?

Background: Hyperparathyroidism is associated with increased bone turnover and fractures. We aimed to determine its prevalence in patients attending our osteoporosis clinic, and investigate relationships between their serum calcium, vitamin D, bone turnover markers, bone mineral density (BMD), DXA T-scores and fracture history. Methods: We identified records from 2003–2017, collecting data on parameters above, and parathyroid imaging. Normal calcium level defined as 2.35–2.50 nmol/litre; normal vitamin D =/> 50 nmol/litre; normal PTH < 2.65 pg/ml. Results: 7624 patients; 364 (4.77%) had elevated PTH; 27 with incomplete data excluded. Of remaining 337, 294 female, 43 male; median age 76, mean T-score spine −2.6, mean T-score hip −2.4; overall osteoporosis prevalence 68.8%; 19% had prior hip fracture, 49% vertebral, and 21% Colles. 16 with eGFR < 30 ml/min excluded. Of the remaining 321, 53 (16.5%) hypercalcaemic, 69 (21.5% normocalcaemic and 199 (62%) hypocalcaemic. 182 had low vitamin D, implying secondary hyperparathyroidism; 139 normal vitamin D, implying primary hyperparathyroidism. Of 139 with likely primary hyperparathyroidism, we compared those with normal calcium level to those with high calcium: No significant differences in BMD spine/hip, prevalence of osteoporosis or fragility fracture. P1NP – a bone formation marker – was significantly higher in normocalcaemic group (mean difference 17.483 ng/ml, p = 0.049). 57 patients had parathyroid ultrasound or isotope scans. 22 positive for adenoma; 35 negative. Scans significantly more likely to be positive in patients with high calcium compared with normal calcium (likelihood ratio 5.671, p = 0.0173, ChiSquare test). 13 positive scans were in patients with low vitamin D. Conclusions: Patients with hyperparathyroidism were relatively older, osteoporotic and had high prevalence of fractures, low serum calcium and vitamin D. Low vitamin D was a poor negative predictor of adenoma. Although normocalcaemic patients were less likely to have a radiologically-proven adenoma, they appeared to carry a similar risk of osteoporosis and fracture as those with high calcium/adenoma.