Background: Denosumab, given 6 monthly as a subcutaneous injection, is well established as a treatment for osteoporosis. In the UK it is initiated in secondary care with most patients continuing with injections in primary care. Given concerns with hypocalcaemia and possible adverse effects on fracture risk due to abrupt cessation, robust monitoring in primary care is important. Our study compares two groups of patients on denosumab, one following a well-defined treatment pathway including a transfer information pack when transitioning to primary care, the other without. Our aim was to evaluate the success of this in improving adherence, reducing inadvertent cessation rates and re-referral.
Methods: We retrospectively formed a database of patients seen in outpatient clinics who had commenced denosumab for the treatment of osteoporosis between January 2011 and January 2018. We identified those who did (group 1, n=257) and did not (group 2, n=57) follow the treatment pathway, including a transfer information pack when transitioned to primary care. Data were collected using standardised proforma including demographics, co-morbidities, biochemistry, cessation rates and re-referral.
Results: Baseline demographics of each group were similar. There was a female preponderance in both (95% (group 1) 96% (group 2). Mean age at commencing treatment was 75 and 72 years respectively. Results are summarized below:
|Category||Group 1 n=257 (%)||Group 2 n=57 (%)||P-values|
|Baseline CTX recorded||247 (96%)||3 (5%)||P=<0.001|
|Baseline DXA||257 (100%)||49 (86%)||P=<0.001|
|Repeat DXA||97 (38%)*||24 (42%)||P=0.54|
|Follow-up spine x-rays||69 (27%)||22 (39%)||P=0.08|
|Injection administration transferred to primary care||245 (95%)||30 (63%)||P=<0.001|
|Management of osteoporosis in primary care||217 (84%)||14 (25%)||P=<0.001|
|Biochemical monitoring (calcium/Vit D checked 8 weeks prior to injection)||128 (50.2%)||16 (32.6%)||P=0.02|
|Re-referral||17 (6%)||9 (16%)||P=0.02|
|Deliberate cessation||25 (10%)||11 (19%)||P=0.04|
|Inadvertent cessation||13 (5%)||16 (28%)||P=<0.001|
|NB some patients excluded in each category due to loss of follow up data. *49% of patients in group 1 were within their first two years of treatment.|
Conclusion: Our study demonstrates the use of a transfer pathway improves the rates of transfer to primary care for both injection administration and follow-up whilst reducing re-referral significantly. Biochemical monitoring showed improvement in patients on the transfer pathway. Most importantly, a transfer pathway reduced the number of patients in whom denosumab was stopped either deliberately or inadvertently.
18 - 21 May 2019
European Society of Endocrinology