1). Analysis of osteoporosis medication prescriptions by departments
From April 2020 to November 2020, the number of BMD measurements using DEXA was analyzed in each clinical department. In total, 1021 DEXAs were ordered in 19 different clinical departments. Gangnam Sacred Heart Hospital is divided into 30 different clinical departments. Therefore, 63.3% of all departments have ordered DEXA (13 surgical and six medical departments). The prevalence of osteoporosis was highest in neurosurgery (38%), followed by endocrinology (36%). The prevalence of osteoporosis was the lowest in gynecology (12%). Endocrinology had the highest number of osteoporosis medication prescriptions of the medical departments, while orthopedic surgery was the most common surgical department. In the medical departments, 36.9% were prescribed in endocrinology, and in the surgical departments, 78.9% were prescribed in orthopedic surgery. The total number of prescriptions was the highest in orthopedic surgery with 618 cases (60.5%), followed by endocrinology (88 cases), neurosurgery (86 cases), and family medicine (77 cases). Prescriptions were also prescribed in urology, plastic surgery, pediatrics, and pulmonology (Table 1).
Table 1
The number of DEXA in different clinics
Department of Clinics
|
Number of orders of DEXA
|
Orthopaedic Surgery
|
618
|
Endocrinology
|
88
|
Neurosurgery
|
86
|
Family Medicine
|
77
|
Obstetrics and Gynecology
|
51
|
Rheumatology
|
26
|
General surgery
|
26
|
Nephrology
|
13
|
Cardiology
|
8
|
Department of Infectious Disease
|
7
|
Anesthesiology
|
5
|
Neurology
|
4
|
Gastroenterology
|
3
|
Hematology and Oncology
|
3
|
Emergency Medicine
|
2
|
Urology
|
1
|
Plastic Surgery
|
1
|
Pediatrics
|
1
|
Pulmonology
|
1
|
Total: 19
|
1021
|
2) Osteoporosis drug analysis
Almost all of the different medications available have been prescribed at our hospital. Romososumab was excluded as prescriptions of this drug commenced just prior to the start of this study (July 2021). Fifty-three different types of drugs were prescribed. Six of these drugs, such as calcium carbonate (11.3%), are over-the-counter medications that can be obtained without a prescription. From recent to 2015, 20 different types of drugs (37.7% out of whole drugs) were launched to our hospital, 14 drugs from 2010 to 2015, and 19 drugs before 2010. Female hormone formulations have been used for a relatively long time, while RANKL inhibitors are relatively novel. The osteoporosis drugs approved by the Korean Food and Drug Administration include bisphosphonate, RANKL inhibitor, parathyroid hormone, tibolone/TESC/SERM, HRT (estrogen and progesterone), calcium and vitamin D, and sclerostin inhibitor (Romososumab). All osteoporosis drugs were divided into six groups, except for the most recently approved sclerostin inhibitor (Romososumab; Table 2). Group 6 (calcium and vitamin D) had 17 different codes, which accounted for 32% of all osteoporosis drugs, and group 1 (bisphosphonate) had 15 different codes (28.3%). Osteoporosis drugs were distinguished by oral and injectable drugs, with 39 types of oral drugs (73.6%) and 14 types of injectables. Oral agents were mostly female hormones (group 5), and injectables had the most bisphosphonate (group 1). The drugs can be divided into single-agent and two or more mixed complexes. There were 12 types of mixed complexes (22.6%), such as bisphosphonate + vitamin D, calcium + vitamin D, and raloxifene + vitamin D.
Table 2
Groups of osteoporosis medication
Number
|
Group
|
Series
|
Code
|
|
121
|
5
|
Estrogen
|
ESTCJ062
|
11
|
1
|
Bisphosphonate +
vitamin D
|
RIS35D3
|
|
122
|
ESTCJ031
|
12
|
AL70D3D
|
|
123
|
ESTD1
|
13
|
AL70D3
|
|
124
|
ESTD2
|
14
|
RIS150D3
|
|
131
|
|
Estrogen + Progestogen
|
CLIM28
|
15
|
IDRO150D
|
|
132
|
ANGELIC
|
21
|
|
Bisphosphonate
(oral)
|
RISED5
|
|
133
|
CLIAN
|
22
|
RISED351
|
|
141
|
|
Progestogen
|
MPGA10
|
23
|
RISED150
|
|
142
|
MPGA51
|
24
|
ALEND701
|
|
143
|
PGN
|
25
|
AL70ET
|
|
61
|
6
|
vitamin D
(active)
|
VDHD32
|
26
|
IDRO150
|
|
62
|
IVDHD31
|
31
|
|
Bisphosphonate
(injection)
|
IIDRO3S1
|
|
71
|
|
calcium
(single)
|
CACO31
|
32
|
IPAMID
|
|
72
|
ICAG
|
33
|
IZDRO2
|
|
81
|
|
calcium +
vitamin D
|
VD10CA1
|
34
|
IZDRO5
|
|
82
|
VD10CA2
|
41
|
2
|
RANKL
inhibitor
|
IDENOS120
|
|
83
|
VD4CA5
|
42
|
IDENOSU
|
|
91
|
|
vitamin D
(oral)
|
VD3T
|
51
|
3
|
Parathyroid
hormone
|
ITERI56
|
|
92
|
VDHD2
|
52
|
ITERI1
|
|
93
|
VD300
|
53
|
ITERI
|
|
94
|
VD70
|
111
|
4
|
Tibolone/
TSEC/
SERM
|
BZDOX
|
|
95
|
VD10ZS
|
112
|
RALOXD
|
|
96
|
VD10DS
|
113
|
RALOX
|
|
97
|
VD250S
|
114
|
ESTBZ
|
|
101
|
|
vitamin D
(injection)
|
IVD100K
|
115
|
BZDOXD
|
|
102
|
IVD3
|
116
|
TIBO
|
|
103
|
IVD300K
|
3). Top-ranked outpatient osteoporosis examinations and prescription analyses
1 Orthopedic surgery
A total of 100 DEXA tests were ordered from October 15, 2020, to March 16, 2021. An average of 0.7 DEXA tests were ordered per day. The average age of the outpatients was 63 years (range: 22-91 years). There were 62 females and 38 males. Eight patients were seen for a fracture, while the rest had a medical condition such as arthritis. DEXA tests showed osteoporosis in 17 patients (17%) with a score of -2.5 or less. The average T-score of the spine was -0.95 (-4.4 to 3.5), and the lowest was L 1, which was 50% of the total patients. The average femoral T-score was -1.41 (-3.9 to 1.7), and the lowest area surveyed was the femoral neck in 87 patients (87%). A significant T-score difference between the spine and femur (i.e., discordance) was found in 40 patients (40%). These were major discordances in three patients and minor discordances in 37 patients.
Thirty-three codes from 23 patients (23%) were prescribed. Of these, 17 (73.9%), five (21.7%), and one patient (4.3%) were prescribed one, two, or three drugs (RANKL inhibitor + oral calcium agents + vitamin D injection), respectively. Group 6 (calcium/vitamin D) had 14 codes (42.4%), followed by nine codes (27.3%) in group 1 (bisphosphonate) and group 2 (RANKL inhibitor) as the third.
2 Endocrinology
A total of 100 DEXA tests were ordered between February 1, 2020 and April 8, 2021. An average of 0.25 osteoporosis tests (DEXA) were ordered per day. The average age of the outpatients was 62 years (range: 30-89 years). There were 88 females and 12 males. A total of 19 patients were diagnosed with osteoporosis related disease and the rest had various endocrine diseases, such as diabetes. The DEXA results showed osteoporosis in 24 patients (24%) with a T-score of -2.5 or less.
The average T-score of the spine was -1.35 (-4.6 to 4.3), and the lowest level was L1 in 41 patients (41%). On average, the femoral T-score was -1.59 (-4.2~1), and the lowest area was the femur neck in 91 patients (91%). Thirty-eight patients had discordance. Thirty-six patients had minor discordance, and two patients had major discordance.
Seventy patients (70%) were prescribed 100 codes. Of these, 32 patients (45.7%), 25 (35.7%), and three patients (4.2%) were prescribed one, two, and three medications, respectively. Group 6 (calcium/vitamin D) was the most common, with 63 codes (63%) followed by group 1 (bisphosphonate) with 30 codes (30%). The SERM series (group 4) comprised six codes (6%).
3 Neurosurgery
A total of 100 DEXA tests were ordered between February 10, 2020 and November 18, 2020. An average of 0.36 osteoporosis tests (DEXA) were ordered per day. The average age of the outpatients was 70 years (range: 29-90 years). There were 58 females and 42 males. Forty-five patients had spinal stenosis, while 22 had a vertebral fracture. DEXA tests showed osteoporosis in 35 patients (35%) with a score of -2.5 or less.
The average T-score of the spine was -1.11 (-4.7 to 5.5), with the lowest at L1 (41 patients). The average femoral T-score was -1.78 (-4.8-1,8), and the lowest area was the femoral neck in 85 patients (85%). Thirty-three patients had discordance. Thirty-three patients (39%) had minor discordance, and three patients had major discordance.
Twelve codes were prescribed in 11 patients (11%). Of these, eight (72.7%) and three patients (27.3%) were prescribed one and two medications, respectively. Of the 12 codes, eight (66.7%) were bisphosphonates (group 1), followed by calcium/vitamin D (group 6) with three codes (25%), and parathyroid hormone (group 3) with one code (9.1%).
4 Family Medicine
A total of 100 DEXA tests were ordered between December 26, 2019 and December 17, 2020. An average of 0.35 osteoporosis tests (DEXA) were ordered on an average per day. The average age of the outpatients was 60 years (range: 33-89 years), with 74 females and 26 males. As for the diagnosis, 35 (35%) of them were health check-up not otherwise specified (z000.01) and disease of the stomach and duodenum unspecified (k 319) were 14(14%). As a result of the DEXA test, 35 patients (35%) were diagnosed with osteoporosis with a T-score of -2.5 or less.
The average T-score of the spine was -1.12 (-4.7 to 1.7), and the lowest level among the vertebrates was L1 in 42 patients (42%). The average femur T-score was -1.79 (-5.1 to 1.3), and the lowest area was in the femur neck in 86 (86%) patients. A significant difference in bone density between the spine and femur, that is, discordance, was found in 44 (44%) patients. Of these, 42 were minor discordance and two major.
Twenty-six codes were prescribed to 20 patients (20%). Fourteen (70%) and six (30%) patients were prescribed one and two medications, respectively. For 26 codes, 15 codes (57.7%) were the most common with calcium/vitamin D (group 6), followed by the seven codes (26.9%) in the bisphosphonate series (group 1).
5 Gynecology
A total of 100 DEXA tests were ordered between February 22, 2019 and January 11, 2021. An average of 0.14 osteoporosis test prescriptions were ordered per day. The average age of outpatients was 53 years (range: 26 to 69). All the patients were females (100%). Uterine myoma was the most common disease, accounting for 24%. As a result of the DEXA test, osteoporosis with a T-score of -2.5 or less was diagnosed in 12 patients (12%). The average T-score of the spine was -0.66 ( -3.4 to 2.1), and the lowest level among the vertebrates was L1, with a total of 47 (47%). The average femur T-score was -0.89 (-3.2 to 1.2), and the lowest area was the femur neck in 92 (92%) patients. A significant difference in bone density between the spine and femur, that is, discordance, was found in 28 (28%) patients. Of these, 26 were minor discordance and two major. A total of 120 codes were prescribed to 79 patients (79%). Thirty-nine (49.4%) and 39 patients (49.4%) had one and two prescriptions, respectively. One (1.2%) was a combination of bisphosphonate + calcium agents and tibolone. Of the 120 codes, 30 were the hormone family (group 5) with 30 codes (25%), followed by tibolone/TSCE/SERM (group 4) with 29 codes (24.2%). There were two in group 1 and two in group 2.
6 Rheumatology
A total of 100 DEXA tests were ordered between April 04, 2019 and February 09, 2021. An average of 0.14 osteoporosis tests (DEXA) were ordered per day. The average age of the outpatients was 63 years (range: 28 to 91). There were 82 (82%) females. Folate deficiency-related disease was the most common disease (22%), and generalized osteoarthritis was the second most common (13%). As a result of DEXA testing, osteoporosis with a T-score -2.5 or less was diagnosed in 20 patients (20%).
The average T-score of the spine was -1.21 (-4.9 to 2.3), and the lowest level among the vertebrates was L1, with a total of 86 (47%). The average femoral T-score was -1.82 (-3.8 to 1.3), and the lowest area was the femoral neck in 92 (92%) patients. A significant difference in bone density between the spine and femur, that is, discordance, was found in 44 patients (44%). Of these, 42 were minor discordance and two major.
Forty-seven codes were prescribed to 37 patients (37%). Among them, 25 (67.6%), one (29.7%), and one (29.7%) patient were prescribed one, two, and three medications, respectively. Of the 47 codes, 26 codes were calcium/vitamin D (group 6: 55.3%), followed by group 1 with 16 codes (34%). Group 2 had three codes.
7 General surgery
A total of 100 DEXA tests were ordered between February 05, 2018 and January 20, 2021. An average of 0.07 osteoporosis tests were ordered per day. The average age of the outpatients was 63 years (range: 28 to 91). Ninety-six were females, and four were males. A total of 78 patients were diagnosed with breast cancer. This is because screening tests are ordered for osteoporosis caused by menopause by inhibiting ovarian function by breast cancer chemotherapy. As a result of DEXA tests, osteoporosis with a T-score -2.5 or less was diagnosed in 16 patients (16%). The average T-score of the spine was -0.88 ( -3.3 to 5.1), and the lowest level among the vertebrates was L1, with a total of 28 (28%). The average femoral T-score was -1.15 (-3.4 to 2.0), and the lowest area was the femoral neck in 72 (72%) patients. A significant difference in bone density between the spine and femur was found in 36 patients (44%), with only minor discordance.
Sixty-eight patients (68%) were prescribed 80 codes. Of these, 58 (85.3%), nine (13.2%), and one patient (1.4%) were prescribed one, two, and three medications, respectively. There were 72 (90%) and five codes (6.3%) in groups 6 and 2, respectively.
The characteristics of the outpatient clinics are presented in Tables 3 and 4.
Table 3
Characteristics of osteoporosis prevalence and DEXA in out-patient department
Department
|
Orthopadic surgery
|
Endocrinology
|
Neurosurgery
|
Family medicine
|
Gynecology
|
Rheumatology
|
General surgery
|
Rate of DEXA
case/day
|
0.7
|
0.25
|
0.36
|
0.35
|
0.14
|
0.14
|
0.07
|
Age
|
63 (22~91)
|
62 (30~89)
|
70 (29~95)
|
60 (33~98)
|
53 (26~69)
|
63 (28~91)
|
63 (28~91)
|
Sex (M:F)
|
38 : 62
|
12 : 88
|
42 : 58
|
26 : 74
|
0 : 100
|
18 : 82
|
4 : 96
|
Diagnosis
(%)
|
Fracture
(8)
|
osteoporosis
(19)
|
spinal stenosis
(45)
|
health check up
(35)
|
uterine myoma
(24)
|
Folate deficiency
(27)
|
breast cancer
(78)
|
Osteoporosis (%)
|
24
|
36
|
38
|
16
|
12
|
28
|
16
|
T-score (Average)
|
-1.06
|
-1.46
|
-1.13
|
-0.61
|
-0.62
|
-1.18
|
-0.90
|
T-score of spine
|
-0.95 ( -4.4~3.5)
|
-1.35 (-4.6~4.3)
|
-1.11 (-4.7~5.5)
|
-1.12 (-4.7~1.7)
|
-0.66 (-3.4 ~2.1)
|
-1.21 (-4.9~2.3)
|
-0.88 (-3.3~5.1)
|
lowest level of spine(%)
|
L1 (50%)
|
L1 (41%)
|
L1 (41%)
|
L1 (42%)
|
L1 (47%)
|
L1 (42%)
|
L1 (28%)
|
T-score of femur
|
-1.41 ( -3.9~1.7)
|
-1.59 ( -4.2~1)
|
-1.78 (-4.8~1.8)
|
-1.79 ( -5.1~1.3)
|
-0.89 ( -3.2~1.2)
|
-1.82 ( -3.8~1.3)
|
-1.15 ( -3.4~2)
|
lowest part of femur (%)
|
femur neck
(87%)
|
femur neck
(91%)
|
femur neck
(85%)
|
femur neck
(82%)
|
femur neck
(92%)
|
femur neck
(86%)
|
femur neck
(72%)
|
Discordance (%)
minor : major
|
40
37 : 3
|
38
36 : 2
|
33
30 : 3
|
44
42 : 2
|
28
26 : 2
|
44
42 : 2
|
30
36 : 0
|
Table 4
Characteristics of osteoporosis management in out-patient department
Department
|
Orthopadic surgery
|
Endocrinology
|
Neurosurgery
|
Family medicine
|
Gynecology
|
Rheumatology
|
General surgery
|
prescription
of medication (%)
|
23
|
70
|
11
|
20
|
79
|
37
|
68
|
Regimen
single
double
triple
|
17
5
1
|
32
25
3
|
8
3
1
|
14
6
0
|
39
39
1
|
25
11
1
|
58
9
1
|
Number of code
|
33
|
100
|
12
|
26
|
120
|
47
|
80
|
Number of 1st drug (%)
|
14 (42.4)
|
63 (63)
|
8 (66.7)
|
15 (57.7)
|
30 (25)
|
26 (55.3)
|
72 (90)
|
Most common medicine
|
group 6
|
group 6
|
group 1
|
group 6
|
group 5
|
group 6
|
group 6
|
2nd common medicine
|
group 1
|
group 1
|
group 6
|
group 1
|
group 4
|
group 1
|
group 1
|
3rd common
medicine
|
group 2
|
group 4
|
group 3
|
group 2
|
group 1,2
|
group 2
|
group 2
|