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The waiting game

GPs paid to reassess all long-term bisphosphonate patients

GPs are being incentivised to reassess all their patients who have been taking bisphosphonates for longer than three years and take low-risk patients off the drugs, in a scheme to cut medication costs.

Under the scheme, introduced by NHS Brighton and Hove CCG last April, GPs are asked to consider a bisphosphonate ‘treatment holiday’ for two to three years in patients who have taken oral bisphosphonates for three to five years.

Patients suitable for the holiday include those whose bone mineral density has remained the same or has improved from baseline, post-treatment femoral neck T-score is greater than −2.5 and no fractures have occurred during treatment. Patients’ fracture risk will be reassessed at the end of the holiday, and bisphosphonate treatment re-prescribed if it is indicated.

But GPs were advised to continue treating patients who have had a previous vertebral fracture and a T-score below –2.

The audit of all patients comes after a review by the US Food and Drugs Administration found a fracture rates were ‘remarkably similar’ in postmenopausal women taking bisphosphonates for over six years, and those who switched to placebo after three to five years of continuous bisphosphonate therapy.

A spokesperson from NHS Brighton and Hove CCG said: ‘No decision on stopping prescribing bisphosphonates would be made without a thorough assessment of the patient.’

She added: ‘The majority of studies of bisphosphonates lasted less than five years. However, the results of a few study extensions suggest that patients with bone mineral density measure as a femoral neck T score greater than  -2.5 after three to five years of treatment and who did not suffer further fragility fractures are unlikely to benefit from continued treatment.’

The CCG is awarding ‘points’ to those practices which carry out the audit, and these can be transferred into cash for a variety of purposes – including buying equipment for treating patients, payment to dieticians or counsellors to give patients advice on diet or life style, or improving the décor of practices.

Dr Louise Warburton, a musculoskeletal GPSI from Shropshire, said that the scheme was ‘unusual’ but could be useful, as many patients take bisphosphonates for years and are never reviewed.

She said: ‘Bisphophonates can make bones more brittle in the long term and there can be increased risk of fractures of the shaft of the femur. Traditionally, patients can be put on them and just stay on them for the rest of their lives without being assessed again. It can be good to give patients a “holiday” from bisphosphonates for two or three years.’

Dr Warburton added, however, that the number of patients referred for bone mineral density tests could increase under the CCG’s scheme, which could bring added costs.

Readers' comments (5)

  • Vinci Ho

    Treatment holiday is probably sensible .Biphosphonates are not without problems - fracture risk , Barrett 's oesophagus/oesophageal cancer? , oesophageal erosions,cumbersome administration of the drug , osteonecrosis of the jaw and even rarely Stevens Johnson's syndrome.
    Many elderly patients actually fancy taking less medication anyway......

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  • I think there needs to be a decent cost-effect analysis on this.

    Increase in radiation vs potential SE of bisphosphonates
    Increase in DXA scan/GP time cost vs saving on medication
    Has assessment of treatment holiday length been done? What about severity of fractures (the study only mations # rates) and likelihood of operative Tx or disability in each group of fracture
    and so forth........

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  • January 14 Drug tariff, alendronic 70mg is 90p for 4 = £32.40 drug cost saved for a three year holiday

    and the cost of DXA to determine if a holiday is appropriate is ?

    I appreciate there are other considerations but as a cost saver does this stack up, unless of course you just stop the medication without checking.

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  • Working on a stroke unit, we are seeing quite a few patients with stroke admitted on alendronate. Our professor has a theory about this, although not proven. I personally have been diagnosed with osteoporosis, but wouldn't touch any of the drugs approved for osteoporosis with a bargepole. I don't want to end up being a fossil.

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  • Research has shown that there is still a reduction in fracture risk within 5 years of Alendronate therapy, reduced to 3 years for patients on Risedronate. NICE also recommends re-evaluation after 5 years of treatment; so why consider stopping after 3 years?
    to note that the radiation risk of a DXA is very small and it can also be done to pregnant women. The cost in B&H is within the £50 -60 range.

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