Shifting bisphosphonate prescribing patterns for fracture prevention: a 24-year national surveillance of men in the U.S. Veterans Health Administration

Q: What was the study designed to evaluate over the 24-year period (1999–2022)?

To evaluate trends in bisphosphonate initiation among older U.S. male Veterans and how demographic and clinical characteristics of men receiving bisphosphonates changed over time.

Q: How did bisphosphonate initiation change after regulatory approval?

Initiation rose sharply after FDA approval of bisphosphonates for men in 2000, peaked in 2004–2005, then declined by about 50% between 2006 and 2012, before plateauing.

Q: What patient characteristics shifted among men who initiated bisphosphonates?

Over time, initiation increasingly involved higher-risk groups: the share of initiators aged <65 decreased, prior fracture became more common, and among those ≥65, the proportion classified as frail rose substantially while non-frail proportions fell.

Sep 30, 2026

Uploaded by Olivia Brown

Examines 24-year trends in initiating bisphosphonate therapy for fracture prevention among older U.S. male Veterans in the Veterans Health Administration, using national data from 1999–2022. Tracks demographic and clinical shifts across periods, including age, race and ethnicity, drug and route, prior fracture history, and frailty (VA-FI for ages ≥65). Identifies substantial changes after approval, subsequent decline, and later concentration among higher-risk and frail men.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages11

Reading Time28 min

AccessFree to download

Abstract

Summary

Purpose

Methods

Results

Conclusion

Introduction

Archives of Osteoporosis (2026) 21:20 [https://doi.org/10.1007/s1](https://doi.org/10.1007/s1) 1657-025-01635-z Shifting bisphosphonate prescribing patterns for fracture prevention: a 24-year national surveillance of men in the U.S. Veterans Health Administration Rachel E. Elam1,2 · Joan C. Lo3,4,5 · John T. Schousboe6,7 · Robert A. Adler8 · Howard A. Fink9 · Susan M. Ott10 · Joshua Barzilay11 · Frances M. Weaver2,12 · Emily Budde2 · Zhiping Huo2 · Reside Jacob2 · Laura D. Carbone2,13 Received: 19 August 2025 / Accepted: 16 November 2025 © The Author(s) 2026 Abstract Summary 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. Keywords Epidemiology · Osteoporosis · Bisphosphonates · Fracture · Age · Frailty Introduction Multiple randomized clinical trials, predominately in postmenopausal women, demonstrate that oral or intravenous (IV) bisphosphonate (BP) therapy following a hip or vertebral fracture substantially reduces subsequent fractures[1, 2] . Although there is less evidence for fracture risk reduction in older men with osteoporosis than for older women, it is generally thought that these drugs have similar efficacy as in Extended author information available on the last page of the article women[3] and that men with a high risk of fracture should be treated[4] . In 2000, alendronate became the first BP approved for the treatment of osteoporosis in men. BPs were available since 1995 for the treatment of postmenopausal osteoporosis in women, and prior to 2002, treatment of women younger than age 65 with BPs for fracture prevention was common[5] . Following this, a number of guidelines were published suggesting that older women be treated for osteoporosis, although some made no specific recommendations for men[6, 7], while others[8–10] recommended treatment for men age 50 and older with T-scores < −2.5 or those with low bone mass or osteopenia (T-score −1 to −2.5) who had a high 10-year probability of hip or major osteoporotic fracture, as determined by FRAX[8]—a fracture risk assessment tool introduced in

FAQs

What was the study designed to evaluate over the 24-year period (1999–2022)?

To evaluate trends in bisphosphonate initiation among older U.S. male Veterans and how demographic and clinical characteristics of men receiving bisphosphonates changed over time.

How did bisphosphonate initiation change after regulatory approval?

Initiation rose sharply after FDA approval of bisphosphonates for men in 2000, peaked in 2004–2005, then declined by about 50% between 2006 and 2012, before plateauing.

What patient characteristics shifted among men who initiated bisphosphonates?

Over time, initiation increasingly involved higher-risk groups: the share of initiators aged <65 decreased, prior fracture became more common, and among those ≥65, the proportion classified as frail rose substantially while non-frail proportions fell.

Sep 30, 2026

Uploaded by Olivia Brown