In the U.S's largest integrated health system, during a 24-year period (1999-2022), bisphosphonate treatment initiation for fracture prevention in men shifted towards higher-risk populations, including older men and those with prior fracture and frailty.
PURPOSE: To evaluate 24-year trends in bisphosphonate (BP) initiation among older U.S. male Veterans and shifts in demographic and clinical characteristics of BP-treated men over time.
METHODS: U.S. national Veterans Health Administration (VHA) data (1999-2022) were queried to identify men aged  ≥  50 years with a first prescription for an FDA-approved BP for fracture prevention. Age, race, ethnicity, BP drug and route, prior fracture, and, in those aged  ≥  65 years, Veterans Affairs Frailty Index (VA-FI), were examined across five time periods. Temporal trends were analyzed using chi-square and nonparametric trend tests.
RESULTS: A total of 298,340 men initiated a BP during 1999-2022, of whom 233,857 (78.4%) were aged  ≥  65 years. BP initiation rose sharply after FDA approval of BPs for men in 2000, peaked in 2004-2005, then declined by about 50% between 2006 and 2012, and then plateaued. Over time, the proportion of BP initiators aged < 65 years declined from a peak of 28.2% during the middle time period (2008-2012) to a nadir of 13.3% during the final years (2018-2022, p < 0.001 for trend). Among the subset of men age 65 and older who initiated BP, the proportion with prior fracture increased from 8.3% in 1999-2002 to 24.5% in 2018-2022 (p < 0.001). Notably, over half of the men who initiated BP during 1999-2002 were classified as non-frail, whereas in the most recent time period (2018-2022), over half of BP initiators were frail (mildly, moderately, or severely) and only 14.8% of them were non-frail (p < 0.001).
CONCLUSION: In the VHA, BP initiating patterns shifted over time towards treating older men, with much larger proportions of men who had a prior fracture and were classified as frail.