Rochelle Walensky, MD MPH, Director of the US Centers for Disease Control and Prevention (CDC), was a featured presenter at the recent American College of Physicians Internal Medicine Meeting 2021: Virtual Experience. In her presentation, titled "COVID-19: Lessons Learned," Dr Walensky discussed racial/ethnic inequities in COVID-19 impact, breakthrough infections, what happened with the Johnson & Johnson vaccine, and variants of concern in the US. 

The slide show that follows is based on Dr Walensky's presentation and includes links to all of the primary studies that she discusses.

COVID-19: Lessons Learned

Articles

CDC Director Rochelle Walensky, MD MPH, was a featured presenter at the recent ACP Internal Medicine Meeting 2021: Virtual Experience, where she spoke about lessons learned during COVID-19. 

ACP: Lessons Learned during COVID-19 Pandemic

A presentation by Clyde Yancy, MD, MSc, is nearly always memorable – his eloquence, passion, and turn of phrase are worth an hour in a frigid hotel ballroom any time. 

While his session today at the American College of Physicians Internal Medicine Meeting 2021: Virtual Experience was via Zoom, his review of the past 12-15 months of research in cardiology, and specifically in heart failure, was no less animated and his messages were clear: 

Use the new HF diagnostic and risk scoring tools to identify at-risk patients and take action. 

Optimize guideline recommended medical therapy for patients with heart failure. 

Pay attention to evolving treatment options for HFpEF.

Be sure to review and understand the evidence that now substantiates the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) fore treatment of heart failure and comorbidities.  

The slide show that follows is based on Dr Yancy's presentation and includes links to all of the primary studies that he discusses.  

is Vice Dean of Diversity and Inclusion, Chief of Cardiology, Magerstadt Endowed Professor of Medicine Chair, and Professor of Medical Social Sciences at Northwestern University Feinberg School of Medicine; Associate Director of the Bluhm Cardiovascular Institute at Northwestern Memorial Hospital, Chicago, IL.

ACP: Clyde W Yancy, MD, gave a comprehensive update on a year's worth of pivotal science in treatment of heart failure. Here are the highlights. 

ACP: Clyde Yancy, MD, MSc Reviews Advances in Heart Failure Research and Treatment 

Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases (NIAID), says that the key to combatting the COVID-19 pandemic is widespread vaccination and public health precautions.

Fauci was taking part in a question-and-answer session during the opening plenary of the American College of Physicians (ACP) Internal Medicine Meeting 2021 along with Gregory Kane, MD, treasurer of ACP; and Darilyn Moyer, MD, executive vice president and CEO of ACP.

He said that the current weekly average infection rate of 16 000 infections a day is too high for the country to start pulling back on public health measures especially with the current prevalence of the B117 variant which has been shown to spread much more easily, even among younger patients.

According to Fauci, the infection rate could fall over the next few months as long as the country continues the push toward full vaccination and observes public health measures.

“It's really going to depend on us, when we really want to get out of this and get back to normal,” Fauci said. “If we really want to do that, we'll wind up going getting vaccinated.”

When asked whether COVID-19 could be eradicated globally, Fauci seemed more confident that it will be eradicated in some countries and controlled in others, but the process will take years and require vaccinating a large portion of the world’s population.

“We've never had any pathogen of any note of seriousness in which … 50% and 60% of the transmissions occur from a person who never will get symptomatic, or who was in the pre-symptomatic stage. That broke all the paradigms of infectious disease because, prior to that, transmissions were always a little bit asymptomatic but dominated by the symptomatic person.”


“We're going to be continually threatened by variants that will come from other countries, which tells us the obvious solution to that is to make sure that we get the entire world vaccinated against (COVID-19),” Fauci said. “Until we do that, I don't think we're going to eliminate this infection. I think it'll be there at a low level; we'll be protected. We may need to get boosted every once in a while, to keep the level of protection up. But we have to look at it as a global problem, otherwise, we're never going to truly eliminate it.”

Fauci said that early in the pandemic the US response was hamstrung by the years-long dismantling of the local health infrastructure, failure to mobilize the private sector early for diagnostics, and the rapid evolution of the situation with little transparency from China. The transmission method of the virus also caught the world by surprise.

“We've never had any pathogen of any note of seriousness in which … 50% and 60% of the transmissions occur from a person who never will get symptomatic, or who was in the pre-symptomatic stage,” he said. “That broke all the paradigms of infectious disease because, prior to that, transmissions were always a little bit asymptomatic but dominated by the symptomatic person.”

As for the country’s success in responding to the pandemic, Fauci highlighted the Trump administration’s Operation Warp Speed which invested billions in vaccine development and pre-purchase as well as the Biden administration’s rollout of the vaccines.

The NIAID head said the timing of the end of the pandemic is really up to the public. 

Fauci: Widespread COVID-19 Vaccination, Precautions Key to Ending Pandemic

As health care providers, we are accustomed to treating patients with obesity (body mass index [BMI] of ≥30 kg/m²) and the associated comorbidities. Helping these high-risk patients navigate their health issues and offering clinical support is what we do every day.

However, research shows that clinicians can positively impact outcomes by taking a more proactive approach before overweight becomes obesity, ie, by treating pre-obesity, classified by the World Health Organization as BMI 25.0–29.9 kg/m

Research has shown that the risk of increased chronic disease and mortality starts at a BMI lower than that which defines obesity. According to 

The Global BMI Mortality Collaboration Trial

, the relationship between BMI and all-cause mortality and cause-specific mortality has a J-shaped curve with the change point at a BMI of 25 kg/m², or pre-obesity, not at 30 kg/m². This BMI benchmark is a call to action for providers to intervene earlier with education for patients whose weight is trending upward, especially as studies show many patients with pre-obesity will transition to obesity.

It is estimated that, taken together, pre-obesity and obesity affect >73% of US adults, creating a health issue that is considered an epidemic in this country. Patient education should begin with alerting patients who have a BMI of ≥25 kg/m² of the significant health risks associated with pre-obesity. Patients may take their increased weight more seriously and be motivated to work to prevent the transition to obesity when they understand the potential medical consequences.

It is important that patients understand the benefits of even a 5% to 10% loss of original body weight. To help increase success, a comprehensive weight loss treatment plan, including lifestyle changes and behavior modification, as well as FDA-approved medications where appropriate, should be long-term with regular physician follow-up.

Working with patients who struggle with overweight of any magnitude is often complicated. Obesity is a chronic, relapsing disease impacted by family history, lifestyle, environmental factors, pre-existing conditions, and psychological issues. Although it may be challenging to treat patients with obesity, using evidence-based strategies and principles of chronic disease management, we can help patients achieve significant health improvements and avoid complications.

Tips you may want to share with patients to get started:

A single diet plan does not work for everyone, but reducing calories is necessary

Keeping a detailed food diary may be helpful

Increasing physical activity can start with a little bit every day

Support groups, both in person and online, can help maintain motivation

As more research is conducted on the factors associated with and the consequences of pre-obesity, more information will be available to help primary care providers support their at risk patients.

More information on treatment for obesity and how to become a member of the Obesity Medicine Association can be found 

Michelle L. Look MD joined San Diego Sports Medicine & Family Health Center in 2001 after completing the Primary Care Sports Medicine fellowship program and Family Practice residency at Sharp Healthcare in San Diego. Dr Look is board certified in family medicine and obesity medicine, with qualifications in sports medicine. She has been a team physician for the United States in several Olympic Games and is currently a staff physician for the US Olympic Training Center in Chula Vista and a team physician for the USA Men’s and Women’s Rugby Sevens Team.

Obesity Medicine Association

Research shows that increased risk of chronic disease and mortality begins below a BMI classified as obesity. The earlier we intervene with at-risk patients, the greater the chance for success.  

 Early Intervention in Weight Management: Treating Pre-Obesity

The patient with overweight or obesity and some level of dysglycemia is a patient seen daily in primary care practice.



The traditional approach to the patient with obesity and a modestly elevated A1c is to advise lifestyle modifications first, followed by a prescription for metformin. The patient with obesity who is diagnosed with more advanced type 2 diabetes (T2D) may be started on double or even triple drug therapy and typically advanced to basal insulin, with additional prandial insulin the next step.

Patient Care Online recently spoke with obesity specialist Silvana Pannain, MD, about her approach to care for this rapidly expanding patient population. In this video, Dr Pannain talks about a weight-centric approach to T2D management and an insulin-sparing regimen now gaining favor. She spoke on both topics today at the Obesity Medicine Association's 2021 Annual Spring Summit. 

, is associate professor of medicine in the section of Endocrinology, Diabetes and Metabolism at University of Chicago Medicine and director of Chicago Weight, an interdisciplinary weight loss program and support group at the University of Chicago.

Videos

For frontline clinicians who care daily for patients with obesity and type 2 diabetes, a weight-centric approach to T2D, including antiobesity drugs, could help improve outcomes. 

A Weight-centric Approach to Obesity with T2D: How Pharmacotherapy Works 

Harold Bays, MD, is widely recognized for his research in cardiometabolic disease and, as he told Patient Care Online during a recent interview, he has been a principal investigator for a long time. "I was there when we developed all the diabetes drugs and antihypertension drugs and lipid drugs."

Bays now is very optimistic about the approval of new medications for the treatment of obesity and says primary care clinicians are going to be essential in getting them to appropriate patients. In this interview he also highlights a topic he discussed in a presentation at the Obesity Medicine Association's Virtual Spring Summit on April 23, 2021: how the 2 words "be inefficient" can change the approach to obesity treatment.   

 is medical director of the Louisville Metabolic and Atherosclerosis Research Center, Inc, Chief Science Officer at the Obesity Medicine Association, and widely known for his research in cardiometabolic disease.

Long time cardiometabolic investigator Harold Bays, MD, talks about obesity, new drugs to treat the disease, and how the words "be inefficient" could change thinking about treatment. 

These Two Words Could Change Obesity Treatment, says Harold Bays, MD 

recently spoke with medical weight management specialist Sandra Christensen, MSN, ARNP, about her upcoming presentation at the Obesity Medicine Association Virtual Spring Summit that begins Friday, April 23, 2021. 

In the video below, Ms. Christensen discusses the unique challenges primary care physicians (PCPs) face when treating patients with obesity, how PCPs can initiate and navigate the complex conversation about obesity with their patients, and why a productive partnership between PCPs and their patients with obesity starts with respect. 

Sandra Christensen, MSN, ARNP, is a medical weight management specialist and owner of 

Ms. Christensen is also a fellow of the Obesity Medicine Association, where she serves on the Board of Trustees, and is a contributing author to the OMA Obesity Algorithm. Ms. Christensen is also the author of, 

A Clinician's Guide to Discussing Obesity with Patients. 

The following has been edited for clarity. 

I’m Sydney Jennings, associate editor of 

. Today I have the distinct pleasure of speaking with Sandra Christensen in advance of the opening of the Obesity Medicine Association’s Virtual Spring Summit held on April 21st where she will be a featured presenter. Ms. Christensen is a medical weight management specialist and owner of Integrative Medical Weight Management in Seattle, Washington, where she provides personalized, comprehensive obesity treatment. Ms. Christensen is a fellow of the Obesity Medicine Association, where she serves on the Board of Trustees, and is a contributing author to the OMA Obesity Algorithm. Welcome, Ms. Christensen.

Thank you, Sydney. It's great to be with you today and I'm super excited to talk about this topic with you and with your primary care audience.

, obesity is associated with the leading causes of death in the United States and the latest data show that rates are only increasing. Although my audience of primary care physicians encounters this growing patient population on a daily basis, the reality of supporting weight loss, as you know, is complex. It can be difficult for primary care physicians to know where to begin with diagnosis and treatment for their patients with obesity. Can you speak to some of the challenges primary care physicians face when treating patients with obesity?

Well, I think there's a long list of challenges that they face. Obesity is the most common chronic condition in the United States for adults and 42.4% of US adults have obesity and another 33% have pre-obesity, which is a BMI between 25 and 30. So, if you think about it, over 75% of US adults are an unhealthy weight. The primary entry point for most people is primary care, and that is overwhelming just right there. So just the sheer number of patients that they have to assess and funnel into treatment. And then we don't have a system that's set up for primary care to really address it. 

People that want to treat obesity a little more seriously in primary care have to set up a separate day, a week, to address it because they just don't have time in their schedules. They have short appointments, and that I think makes it really difficult. And then we don't educate clinicians in their preparatory programs. Not in med school, not in nurse practitioner school, physician assistant school, even though that's changing some, we're making efforts, they didn't get any education on it. So here they are faced with all these patients that have this very serious chronic condition and no education on how to do it. Very little continuing education, although that's improving. 

Reimbursement is a challenge as well, and knowledge of how to code an appointment, whether or not insurance will cover it. So I just think there's numerous challenges for people. Also, people with obesity tend to have complications that are pretty serious. And so their time is spent focusing on those, rather than being able to address the root issue. I have a lot of compassion for the challenges that primary care clinicians have for sure.

These challenges are the basis of your upcoming presentation at the OMA spring summit, "A Real World Approach to Treating Obesity in Primary Care." Could you briefly explain the aim of this presentation?

Well, what I really want to do is help primary care clinicians see the value of addressing it, despite all those barriers, to see how addressing obesity will really improve the health of their patients, and ultimately make their lives easier as well, right? Like, if they spend all their time chasing after the complications and never get to the root, then things aren't going to improve for them either. So I really want to help them see that it's possible, that it's important, and that it's possible to do it, even if it's just small ways.

One of the topics that you're going to talk about is initial interventions that primary care physicians can take to stabilize obesity. I was wondering if you have any tips that primary care physicians can use to help initiate conversations about obesity with their patients? That initial conversation can be quite difficult sometimes.

It can be quite difficult. And that's another area where nobody gets any education, right? We're not taught how to bring that up. And what's different about obesity than other conditions is that it's mired in so much bias and stigma that clinicians are either afraid to bring it up because they don't want to offend the person, or the person shies away from it. You know, the patient, because they've had so many bad encounters. 

So, one of the most important tips about raising the issue of obesity that's different than other conditions is that we want to ask their permission. "Do I have your permission to discuss your weight? Would it be all right if we discuss your weight?" Now, that's very different than other conditions, right? We don't ask someone, "Would it be okay if we talked about your A1c?" Or, "Would it be alright if we talk about your LDL or your blood pressure?" Those are not conditions that are mired in the bias and stigma that obesity is, and most people by the time they encounter a clinician have had some really significantly biased and negative encounters with health care. All areas of health care, as well as society, employment, and all those other places. So, to develop a partnership by conveying respect of that person's desire to talk about it with the clinician is really important. And that act alone can really build a lot of goodwill and be the beginning of a really productive partnership on the topic. So that's a great way to do it. 

And there can be other strategies that can be used, like, "we screen all our patients for weight issues and your screen was positive today. Would it be alright if we discuss your weight?" So there's different ways to bring it up, but a lot of it is conveying respect and tenderness and compassion, rather than being judgmental.

Primary care physicians face unique challenges when managing patients with obesity, but one obesity specialist aims to show clinicians how to meet them, even if it's in small ways. 

Starting a Dialogue about Obesity in Primary Care: Respect is Key

Using the example of studies of weight loss among participants on the reality television show "The Biggest Loser," Dr Silvana Pannain explained in an interview with Patient Care Online the pathologic decrease in energy expenditure that accompanies significant weight loss. NIH researchers who followed participants for 6 years found that despite continuous effort to maintain the average 30% weight loss achieved during the 30 weeks of filming, participants gained back an average of two-thirds of the weight originally lost. 

In the video below, Dr Pannain describes the metabolic adaptation behind this weight regain and how essential it is to counsel patients on the body's defense to weight loss. She will be a featured speaker at the Obesity Medicine Association's Virtual Spring Summit that begins Friday, April 23, 2021. 

Citing a study of "The Biggest Loser" participants, obesity expert Dr Silvana Pannain explains why "Eat less, exercise more," often backfires as a sole intervention for persons with obesity.  

Obesity Expert Discusses an Unexpected Metabolic Response to Weight Loss 

Dr Keith Ferdinand, a prominent cardiologist and lifelong New Orleans resident, has long been outspoken on the issue of inequities in health care for minority communities. The disparities in morbidity and mortality between White populations and populations of color are driven not by biology or genetics but by social determinants that are structural, socioeconomic, and deeply rooted, he says. 

The body of evidence that supports the impact of social determinants of health has expanded many times over since the COVID-19 pandemic began. At the Obesity Medicine Association's Virtual Spring Summit, opening on Friday, April 23, 2021, Dr Ferdinand will talk about the combined impact of COVID-19 and obesity on Black communities. 

Dr Ferdinand gave Patient Care Online a short preview and answered our question on how he would challenge primary care providers to incorporate the harsh lessons the pandemic is teaching.   

“There is a long, persistent, and unacceptable gap in mortality between Black and White Americans, with life expectancy shorter for both Black men and women than for White Americans.

I call this the White- Black Death Gap, and it is primarily driven by disparities in cardiovascular disease.

The prominent disparity in years of life expectancy lost as a result of COVID-19—2.7 years lost for Blacks vs 0.8 years for the general population—means that the White-Black difference in life expectancy will not only persist but will widen as more Black lives are lost to COVID-19 compared to the population at large.”

holds the Gerald S Berenson endowed chair in preventive cardiology and is professor of medicine at the Tulane University School of Medicine and the Tulane Heart and Vascular Institute in New Orleans.

The following transcript has been edited lightly for clarity. 

: So, it's been painfully clear since the beginning of the COVID-19 pandemic, that mortality among African Americans has trended higher than among other racial and ethnic groups. In fact, I think it's been almost one year since your editorial appeared in the Journal of the American College of Cardiology, where you identified African American COVID-19 mortality as a sentinel event. I don't know if it's possible to summarize the experience of a year in a short interview but what does the medical community know today that it didn't know in April 2020 about COVID-19 infection and risk in the African American community?

 Well, let's go back a year. I'm here in New Orleans, which was one of the epicenters. Mardi Gras was February 25, 2020. It was a glorious day I was out there with the second line bands. And then about March 9, we had our first case, and we think it was the 300 000 visitors who came in and that someone probably internationally brought COVID-19. So along with Seattle, New York, New Orleans was one of the epicenters. I think what we've learned is that certain populations, including African Americans, Hispanic, LatinX populations have high rates, but it's not genetic. It's the social determinants of health. Those essential workers early on, the grocery clerks, the transit operators, the delivery persons who are being exposed with people were sneezing and coughing and breathing on them. And at that time, there was no personal protective equipment. There were no barriers that were up at that time. The other thing that we learned is that persons who live in socially stressed environments, multigenerational homes, not having access to early testing, were more prone to become more sick, have more hospitalization. And once you have hospitalization, of course, you have an increase in deaths. It's had a profound effect on longevity, and I would like to bring that point out.

 So as an underlying condition or comorbidity, obesity increases the risk of severe COVID-19, almost geometrically anyway, and it has earned a spot as one of the most dangerous comorbidities. By some estimates, about half of the African American community suffers from obesity, which is an added factor that can spark the inflammatory storm that we see often. Could you talk a little bit about the link between inflammation and severe COVID-19 infection?

 Well, we know the most powerful risk factor for being hospitalized and dying is age. And in fact, 80% of deaths are related to persons who are 65 years and older whereas if you look in some of the cohorts in the African American population, you see the mean age is about 60, about 5 years younger than would be expected and perhaps the strongest driver in that population is obesity. Obesity, of course causes mechanical obstruction of ventilation and difficulty being placed in the prone position which we found was optimal for respiration. But also, obesity is related to an inflammatory state. Cytokines which are released with infection with coronavirus are also baseline higher in persons with obesity; we know there are high levels of C-reactive protein, interleukin-6. So now you have a condition where the inflammatory state is already heightened. You add a virus which causes an increase in cytokines, and that kind of up regulates the inflammatory state and makes it even more a problem in terms of persons who become ill, with increased hospitalization and unfortunately increased death.

 So, you're a clinician who has lived and worked in the community that you care for probably for most of your career. And I sense you provide probably a little bit more than cardiovascular care and you community. So, we talked to an audience of primary care clinicians, IMs, GPs, Doctor of Osteopathic, and their primary job is to promote wellness and to prevent morbidity and mortality. How would you challenge them, in what will we hope one day be a post COVID-19 health care world, to use what this crisis has shown us more starkly than ever before about healthcare inequalities?

: Remember, I’d like to revisit longevity, but let's talk about various risk factors. As a cardiologist, I have to deal with those risk factors—hypertension, diabetes, high cholesterol, obesity, but it is the primary care providers, they're the frontline workers who are going to control the epidemic of cardiovascular disease we see related to and unrelated to COVID-19. And in fact, if you look at some of the best ways to reduce the burden of heart disease and stroke, it's control of risk factors. And the providers, primary providers, whether they be internist, primary care doctors, family medicine, doctors, nurse practitioners, physician assistants, clinical pharmacists, they actually do a better job and treat more patients for control of cardiovascular risk factors than the cardiologist. Unfortunately, so many of our younger cardiologists are now enthralled with doing procedures and putting in devices and that's important for the individual patient. But if you look at the public health burden of cardiovascular disease, it is primarily controlled by primary care providers.

 And that's where they need to be laser focusing attention as we as we go forward.

I have one other pandemic related question and that is related to telemedicine. I'm wondering how you and your patients fared, needing to deploy telemedicine practically overnight, and whether there have been some unexpected benefits to the use of telemedicine?

 Well, that's one of the hidden gems of the COVID-19 pandemic. It allowed us to learn the benefits of telemedicine. I did a lot of virtual visits. And one of the important things was that for the control of risk factors, you probably can do much of that virtually. The patient needs to have a valid blood pressure device. And I suggest you go to 

, to get a valid blood pressure device. And their means now some of them relatively inexpensively can Bluetooth to an app and the physician can see their blood pressure; there are even Bluetooth scales. Patients know how to do their temperatures. If they have blood drawn—and many of my patients were afraid to come into the hospital setting—they can do it in an outpatient lab. And then we can electronically access those results. So, you then can see the patient over the Internet to talk to them about their symptoms. They can tell you their vitals and you can make assessments in terms of medications. They can go to the local pharmacy and pick them up and never come into an inpatient hospital or clinic setting.

 So, it's probably here to stay as an as an element of healthcare in your estimation.

 The thing we need to overcome is the literacy gap related to IT literacy. Some of my older patients really had difficulty accessing how to do the virtual visits, they had smartphones, but they use them to call grandkids—they never used them to access the Internet. So, we need to build into that some education.

 I want to thank you very much for your time today and all the best in New Orleans.

Keith C Ferdinand, MD, discusses how deeply-rooted social determinants of health have led to the vastly disproportionate impact of COVID-19 on persons of color. 


Keith C. Ferdinand, MD: COVID-19, Obesity, and the African American Community 

Research results presented at ENDO 2021 suggest that fewer than 10% of commercially insured patients who experienced a hip fracture had been prescribed any treatment for osteoporosis within the 6 months before the fracture.

The findings are based on an analysis of insurance claims data from more than 1.4 million patients that also found a significant drop over the past decade (from 15% to 8%) in rates of treatment for osteoporosis. The trend is of note because during the same time there have been multiple new osteoporosis therapies introduced, some with novel mechanisms of action.

“This very low rate of treatment with bone-directed medications to prevent future fractures is concerning,” said lead investigator Sara Cromer, MD, an endocrinology fellow at Massachusetts General Hospital, in 

 from the Endocrine Society. “This is analogous to providing no therapy to lower blood pressure or cholesterol after a heart attack.”

With her colleagues from Massachusetts General and the Brigham and Women's Hospitals, Cromer searched claims data entered into the Clinformatics Data Mart for enrolled individuals over age 50 years who were prescribed any osteoporosis medication during each quarter between January 1, 2009 and March 31, 2020. Subgroup analyses limited the population to 2 groups based on ICD codes:

ICD codes for osteoporosis in the current or previous 3 quarters and without codes for active malignancy during the current or previous quarter

ICD codes from an oncology provider for active malignancy likely to metastasize to bone during the current or previous quarter

According to the Centers for Disease Control and Prevention, every year >300,000 adults aged ≥65 years nationwide sustain a hip fracture requiring hospitalization.

In the all-user cohort, 15.48 million unique prescription or medication administration claims from 1.46 million individuals were analyzed. Women comprised 89% of this group and 71% were older than age 65 years (mean age 69). The percentage receiving individual medications was calculated.


The most common medication used was the bisphosphonate alendronate, representing >50% of all treated individuals and with use increasing over the study period. Analysis showed that use of zoledronic acid, the once-yearly intravenous bisphosphonate, doubled during this period but remained at <5%. There was a steady decline recorded in use of other bisphosphonates as well.

Use of injectable osteoporosis medications (teriparatide and abaloparatide, self-injected daily; romosozumab, physician injected monthly) remained at <2% throughout the study period. The percentage of individuals treated with raloxifine, a selective estrogen receptor modulator, declined after 2013.

In significant contrast, use of the twice-yearly injectable monoclonal antibody denosumab increased rapidly after its approval in 2010, used by 10% of claimants in 2015 and by 15% in 2018.

Trends in the osteoporosis cohort paralleled those in the all-user cohort.

Analysis of the malignancy cohort found use of alendronate and zoledronic acid of approximately 30% at the study's beginning followed by a steady decline. Denosumab use, on the other hand, surpassed use of either of these bisphosphonates by 2013, becoming the most commonly used drug for prevention of fractures related to cancer. Denosumab use reached approximately 50% of all bone-directed medications used in this cohort. Use of other medications in the malignancy cohort, mainly alternate bisphosphonates, was low and declined throughout the study period.

Lead study author Cromer commented in the Endocrine Society statement that the rapid rise in use of denosumab seemed out of proportion with the Society’s 

 that the injectable medication be used as an alternative to bisphosphonates for the initial treatment of osteoporosis if a patient cannot take bisphosphonates or is at high risk of osteoporotic fractures.

“While denosumab is highly effective at improving bone density and preventing fracture," said Cromer, "it has also been known for several years that there is an increase in spinal fractures if denosumab is discontinued without follow-up treatment, and sometimes even with follow-up treatment.” She continued, “This safety concern does not seem to be reflected in medication use as of early 2020, the end of our study.” Cromer noted that the reasons for the rapid increase in use of denosumab remain unclear.

Reference: Cromer S, D'Silva KM, Yu EWY, et al. 

Temporal trends in prescribing of bone-directed therapies in the United Sates, 2009-2020.

 Presented at ENDO 2021, March 20-23, 2021. 

For more coverage of ENDO 2021, please click

ENDO 2021

ENDO 2021: Fewer than 1-in-10 older adults with a hip fracture had been prescribed bone-directed  treatment in the 6 months prior to the incident, according to research on trends in treatment. 



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