Quality Improvement Project: Improving Osteoporosis Treatment for Patients with a Neck of Femur Fracture

Background/Aims The Fracture Liaison Service (FLS) identifies patients >50 who have sustained a fragility fracture (FF). These patients need prompt assessment and decision on appropriate treatment for osteoporosis in order to reduce their risk of sustaining further FFs. Without treatment, 1/5 patients can go on to have a further FFs which carry significant risk to mortality and morbidity. Zoledronate is a bone agent that halves the risk of another FF. Patients with a neck of femur fracture (#NOF) present as one of the most at-risk groups for a further FF. These patients are generally elderly and frail and attendance to outpatient hospital appointments are difficult. Therefore, transforming the FLS from an out-patient-based service, to one that is streamlined to systematically identify and opportunistically treat patients whilst they are still in hospital means delivering timely, effective and efficient patient-centred care. Methods We used various Plan-Do-Study-Act cycles to aim to deliver Zoledronate to>=90% of appropriately assessed in-patients >60 who have had a #NOF within a year of commencing QIP. Results PDSA cycle 1-Involvement of ortho-geriatrician: P-Improve working relationship with ortho-geriatrician with an interest in bone health over a 6-month period;D-Regular meetings with wider MDT;S-Priority of bone health assessments made greater through ward round documentation;A-Expand knowledge throughout the wider ortho-geriatrician team. PDSA cycle 2-Timing of Zoledronate delivery: P-Literature review regarding delivery of Zoledronate timing;D-Discuss as MDT;SNo evidence to suggest delay in fracture healing if given on day 7;AAdopted process and communicated. PDSA cycle 3-FLS team on the wards as a result of PDSA cycle 2 not improving treatment outcomes: P-FLS nurses to join ortho-geriatrician ward round twice-weekly for 3- month trial period;D-Bank holidays and spike in Covid cases presented a challenge. Solution: Improvement of MDT relationships;S-At the end of the trial period an increase in patients who received treatment was shown and proved our prediction;A-Adaptation to documentation in FLS to streamline and reduce duplication. Conclusion The ability to deliver Zoledronate to>=90% of appropriate patients with a #NOF as an inpatient was reached after 8 months of initiating QIP. Furthermore, maintaining this was consistently achieved throughout the following year and beyond. A few of the main reasons for this included earlier drug delivery, having a dedicated ortho-geriatrician as part of the FLS, and the FLS team attending the wards. A prompt bone health assessment of patients has enabled appropriate treatment to be delivered efficiently. The delivery of Zoledronate as an in-patient has meant that a significantly greater proportion of patients receive treatment, and sooner, in comparison to awaiting an outpatient assessment (that they may not attend). Therefore, this QIP has demonstrated time- and cost-effective management of patients with #NOF requiring Zoledronate.

Safety and effectiveness of once-yearly zoledronic acid in Japanese osteoporosis patients: three-year post-marketing surveillance.

INTRODUCTION: Zoledronic acid (5 mg; ZOL), a once-yearly bisphosphonate, reduces osteoporotic fractures and increases bone mineral density (BMD). This 3-year post-marketing surveillance examined its real-world safety and effectiveness. MATERIALS AND METHODS: This prospective, observational study included patients who started ZOL for osteoporosis. Data were assessed at baseline, 12, 24, and 36 months for safety and effectiveness. Treatment persistence, potentially related factors, and persistence before and after the COVID-19 pandemic started were also investigated. RESULTS: The safety analysis and effectiveness analysis sets included 1406 and 1387 patients, respectively, with mean age of 76.5 years. Adverse reactions (ARs) occurred in 19.35% of patients, with an acute-phase reaction in 10.31, 1.01, and 0.55% after the first, second, and third ZOL infusions. Renal function-related ARs, hypocalcaemia, jaw osteonecrosis, and atypical femoral fracture occurred in 1.71, 0.43, 0.43, and 0.07% of patients, respectively. Three-year cumulative fracture incidences were 4.44% for vertebral, 5.64% for non-vertebral, and 9.56% for clinical fractures. BMD increased by 6.79, 3.14, and 1.78% at the lumbar spine, femoral neck, and total hip, respectively, after 3-year treatment. Bone turnover markers remained within reference ranges. Treatment persistence was 70.34% over 2 years and 51.71% over 3 years. Male, age ≥ 75 years, no previous medicines for osteoporosis, no concomitant medicines for osteoporosis, and inpatient at the first infusion were related to discontinuation. There was no significant difference in the persistence rate between before and after the COVID-19 pandemic (74.7% vs. 69.9%; p = 0.141). CONCLUSION: This 3-year post-marketing surveillance confirmed the real-world safety and effectiveness of ZOL.

All in the Marrow - a Case of Primary Bone Marrow Oedema

Introduction/Background: Primary bone marrow oedema syndrome is an elusive and less well-defined entity. Whether Rheumatologists should consider it as a stand alone diagnosis, is debatable. It possibly would be best described as an MRI feature which could be a finding in a number of diseases which would include the initial phases of Osteonecrosis of the bone, Rheumatoid Arthritis, Spondyloarthritis, Enthesitis related, Post traumatic, OA, Infections and Cancers. The treatment options become constricted due to the paucity of evidence. Rheumatologists need to consider this as an area of unmet need with development of consensus classification criteria and treatment approaches. Description/Method: 27-year-old male, Height 174 cms Weight 90 Kgs BMI 29 Kg/m2, became symptomatic in Jan 2022 with complains of pain in the both hip joints & groin regions, pain became excruciating and he became bed-bound, with early morning stiffness lasting approximately 45 mins. Had received steroids for COVID infection in August 2020. Investigations Hb 13.5gm/dl TLC 7000/mm3 Platelet 400 x 103/mm3 Sr Bil 0.8mg/dl AST 16 IU/L. ALT 24 IU/L Sr Creatininine 1.1mg/dl Blood Sugar Levels, Fasting 89 mg/dl Post Prandial 102 mg/dl ESR 10mm in 1st hour by Wintrobes method CRP Quantitative 29.38mg/L HLA B27 by PCR Negative, RF Negative, ACCP Negative Serum, IgG, Beta2 Glycoprotein 1.44 SGU Serum, IgM, Beta2 Glycoprotein 3.44 SGU Serum, IgG, Cardiolipin antibody 8.4 GPL Serum, IgG, Cardiolipin antibody 17.45 GPL Lupus anticoagulant by DRVVT Negative Sr Cholesterol 211mg/dl HDL 29 mg/dl LDL 156mg/dl TGs 130 mg/dl MRI Hips & SI joints Transient bone marrow oedema/osteopenia of bilateral hip. PET CT Increased metabolic activity in both hip joints Bone Scan (99mTcMDP) Increased vascularity in perfusion phase, increased accumulation in soft tissue in blood pool phase and increased uptake in bilateral Hip joints in skeletal phase scan, suggestive of CRPS Type-I. Management Was initially managed with Tab Etoricoxib 90mg BD, also started on Tab Sulphaslazine and Tab Methotrexate. However, when he had no symptomatic relief he was administered Inj Infliximab on 12 May 2022 and a second dose on 9 June 2022. He had excellent pain relief after the 1st dose, however after 10 days of the administration, he again began experiencing pain especially after walking. He also had pain in the knees on this occasion. He was also administered Inj Zoledronic 4mg on 23 May 2022. He is at present not requiring any NSAIDs over the last 1 month. Discussion/Results: The patient having presented with excruciating and debilitating pain was worked up and evaluation revealed features of bone marrow oedema on MRI which was corroborated with bone scan and PET CT imaging. The acute phase reactant CRP was also significantly elevated. The patient also gave history of early morning stiffness lasting approximately 45 mins. Hence an underlying Inflammatory process such as Spondyloarthritis(Peripheral) with enthesitis was considered. The confounding factors were the pain which worsened on mobilization, HLA B27 negative status, Rheumatoid Factor and ACCP negative status and past history of having received IV Corticosteroids for COVID infection in August 2020. In view of the debilitating pain and aworking diagnosis of Spondyloarthritis, hewas started onNSAIDs alongwith rest, initially, followed by conventional synthetic disease modifying agents in Rheumatic disease followed by biologic synthetic diseasemodifying agent - Inj Infliximab. The thought process was to avoid prolonged NSAID use to prevent the associated side effects. However, since Avascular Necrosis of the Femoral head is a very likely possibility, the patient is planned to be kept under close follow up. Key learning points/Conclusion: Collaborative efforts between the Departments of Nuclear Medicine, Radiology, Orthopaedics and Rheumatology are crucial in the early detection and approach to cases of Bone Marrow oedema. Avascular necrosis of head of Femur is a far more common entity and must be kept in ind even when a diagnosis of Bone Marrow oedema syndrome is being entertained. Diagnosis of Bone Marrow oedema syndrome must be entertained only as a diagnosis of exclusion. Continued follow up and regular imaging must be pursued rigorously in patients diagnosed with Bone Marrow oedema syndromes. There is a requirement to document acute phase reactants such as CRP and ESR in patients diagnosed with Avascular necrosis of bone as this data could help us differentiate AVN from Primary Bone marrow oedema in the early stages.

Abstracts of the Joint Annual Meeting of the Swiss Society of Rheumatology and the Swiss Society of Physical Medicine and Rehabilitation

The proceedings contain 47 papers. The topics discussed include: increased humoral immune response after vaccination with mRNA-1273 vs BNT162b2 in patients with inflammatory rheumatic diseases;comparison of anti-fracture effectiveness of denosumab versus bisphosphonates in a registry-based, real-world cohort study;comparison of drug retention of TNF inhibitors, other biologics and JAK inhibitors in patients with rheumatoid arthritis who discontinued JAK inhibitor therapy;BRD3 regulates the inflammatory and stress response in rheumatoid arthritis synovial fibroblasts;effect of methotrexate and folic acid co-administration in arthritis;early anti-S antibody levels predict anti-SARS-CoV-2 neutralizing activity over 24 weeks in RA patients after SARS-CoV-2 mRNA vaccination;effect of zoledronate on bone mineral density and bone turnover markers after long-term denosumab therapy: observations in a real-world setting;and developing a screening tool for the detection of interstitial lung disease in systemic sclerosis: the ILD-RISC score.

ANTIOSTEOPOROTIC TREATMENT and COVID-19 RISK: IS THERE AN ASSOCIATION?

Background: Nowadays, the COVID-19 and its complications are considered an important medical issue with aggravated medico-social outcomes, both at the worldwide scale, and in terms of various individual countries. Despite the recent ASBMR, AACE, Endocrine Society, ECTS and NOF recommendations according to osteoporosis management in the era of COVID-19 the influence of antios-teoporotic drugs on disease incidence and severity continue to be studied [1, 2]. Objectives: The purpose of this study was to assess the COVID-19 risk for the patients receiving the parenteral bisphosphonate or Denosumab treatment, and the severity of its course in the systemic osteoporosis patients. Methods: We performed the phone survey and studied the results of 195 patients (92 % women;mean age-62.7±10.8 years, height-161.0±8.0 cm, body weight-68.9±12.3 kg) with systemic osteoporosis depending on the current use of parenteral antiresorptive drugs (Zoledronic acid, Ibandronic acid, or Denosumab, n=125) and compared the results with patients with osteoporosis who did not use any antiosteoporotic drugs previously (n=70). The mean duration of antiosteoporotic treatment did not vary across the groups, accounting for 15 [9-27] months. Prior to the beginning of the antiosteoporotic therapy, all the patients had a confrmed diagnosis of osteoporosis at the Ukrainian scientific-medical Center of osteoporosis. Results: We did not reveal any signifcant differences in the COVID-19 frequency and severity depending on the presence and type of parenteral antiosteoporotic therapy. Additionally, there were no differences depending on patients' age of sex, obesity presence, and other osteoporosis risk factors. The risk of COVID-19 in the patients with systemic osteoporosis did not differ depending on antiresorptive drug use, amounting (Odd Ratio (OR) 95 % CI) to 1.1 (0.6-2.0), or on the use of the defnite antiosteoporotic drug (for the Zoledronic acid-0.9 (0.4-2.0), the Ibandronic acid-1. 1 (0.5-2.3), and for the Denosumab-1. 6 (0.5-5.2). Conclusion: Our study did not reveal any signifcant differences in the COVID-19 frequency and severity depending on the presence and type of parenteral antiosteoporotic therapy. We conclude that parenteral antiosteoporotic drugs (Zoledronic acid, Ibandronic acid, or Denosumab) do not have an influence on COVID-19 frequency and severity and can be recommended for the continuation of treatment of patients with osteoporosis.

Enhancing Pandemic-Sensitive Recruitment Strategies for a Remote, Randomized Placebo Controlled Trial for Fracture Prevention in Patients with Neurodegenerative Parkinsonisms

Objective: To develop a diversified recruitment model for the ongoing Trial of Parkinson's and Zoledronic Acid (TOPAZ) during the COVID-19 pandemic. Background: TOPAZ is a home-based trial examining the efficacy of zoledronate in preventing fractures in people with neurodegenerative parkinsonisms, who have up to 4-fold increased fracture risk. Design/Methods: Consent is obtained online (https://www.topazstudy.org). After eligibility is determined by movement disorders specialists using medical records and/or telemedicine, study drug is infused by research nurses at home. Fractures are ascertained by email or telephone. The 2/2020 onset of recruitment coincided with COVID-19 restrictions, with a nearly 7 months pause. To randomize 3,500 participants by 12/2023, we developed multiple methods to recruit potential participants via: 1) 46 Parkinson Study Group (PSG) sites, 2) 11 health care systems with integrated research networks, 3) community outreach organizations (i.e. support groups, social media, newsletters, etc.), 4) outreach by the Parkinson's Foundation (PF), 5) Fox Trial Finder (FTF), and 6) the 23andMe Parkinson's disease research program. Results: By 10/1/2021, 2002 had registered on the website, 1333 consented, 992 were eligible per expert diagnostic confirmation, and 632 were randomized, exceeding our goal of 600 for 9/30/21. Registered participants came from the multiple sources: 1) 609 (27.7%) from PSG sites, 2) 529 (24%) from health care systems with integrated research networks, 3) 213 (9.7%) from community outreach, 4) 34 (1.5%) from PF, 5) 16 (0.7%) from FTF and 6) 601 (27.3%) from 23andMe. The largest source of recruitment was PSG. A single study invitation emailed from 23andMe to its 19,733 PD research participants led to nearly the same number of referrals as PSG but in only a few weeks'time. Conclusions: Using diverse referral sources to the TOPAZ study website, we are succeeding in achieving enrollment targets for a Parkinson's trial amidst the challenges of the COVID-19 pandemic.

Audit of zoledronic acid prescribing for multiple myeloma at North Bristol NHS Trust (NBT)

Background: Bone loss is a well-recognised complication of myeloma, affecting up to 90% of patients. It is associated with fractures, spinal cord compression and hypercalcaemia. 1,2 Myeloma patients are routinely prescribed zoledronic acid, which has been shown to prevent skeletal-related events, preserve bone density and prolong progression-free survival.3 At NBT, zoledronic acid is prescribed on a paper prescription chart, which is not routinely reviewed by a pharmacist This process is not in accordance with other therapy, which is prescribed on ChemoCare and clinically verified by a pharmacist prior to administration. Objectives • To assess the adherence of zoledronic acid prescribing at NBT against the South West Clinical Network (SWCN) protocol. • To identify areas for improvement in the prescribing of zoledronic acid for prevention of skeletal events. Standards: 100% of patients receiving zoledronic treatment should meet the following go-ahead criteria:4 • Acceptable bloods within seven days of treatment (creatinine, calcium, phosphate, magnesium) • Comprehensive dental examination. • Dose modification based on creatinine clearance. • Treatment deferred if hypocalcaemia or hypophosphataemia. Methodology: The audit was conducted over a one month period between 1/11/2020 and 30/11/2020. A total number of 58 prescriptions were included in the audit. The data collection sheet for the audit included;patient details, date of treatment and zoledronic acid dose. This information was extracted from the drug charts. The information system ICE was used to verify the blood results and validity period. Creatinine clearance was calculated using the Cockcroft and Gault equation. The medical notes were reviewed for evidence of dental checks. Data was recorded on Excel for further analysis by the pharmacist. Results: An overview of all four audit standards is shown in Figure 1. Two of the four audit standards were fully met (standards 2 and 4). 2% of patients (n= 1/58) did not receive an appropriate zoledronic acid dose adjustment based on renal function (standard 3). 36% (n=21/58) of patients did not have bloods within seven days of treatment (standard 1), however all of these patients had bloods within a month of treatment, in line with the Summary of Product Characteristic recommendations.5 Discussion and conclusion: The audit demonstrated that adherence to zoledronic acid prescribing guidelines is generally satisfactory;however several areas for improvement were identified. Feedback was provided to the haematology team and the following recommendations made: • Critical bloods must be done within one week of treatment. • Evidence of a dental examination must be clearly documented. • An approved app must be used for calculating creatinine clearance. • Introduction of a pharmacist clinical verification. • Zoledronic acid should be prescribed on ChemoCare, to assist with the above recommendations. Limitations: This audit was only carried out over a month which will only provide a snapshot of prescribing and results may have been impacted by the COVID-19 pandemic. It was difficult to find documentation for dental checks and treatment delays due to bloods and in some cases, information had to be verified by the prescriber.

PHARMACIST-LED OSTEOPOROSIS TELEPHONE SERVICE

Background/Aims The COVID-19 pandemic has made finding ways to consult suitable patients remotely a priority. We have introduced a telephone assessment clinic, run by our departmental pharmacist, to assess and treat patients with osteoporosis who have been referred from primary care for consideration of parenteral bone sparing therapy. Methods Patients with osteoporosis who have been referred from primary care were triaged electronically into a fortnightly telephone assessment clinic, according to pre-specified criteria. Prior to the appointment, information leaflets about osteoporosis, and treatments for this condition were posted to the patients. The telephone consultation was carried out and patient demographics, risk factors for fracture, bone density results, FRAX / NOGG assessment, treatment decisions, and other clinical details were recorded on a pro-forma. A satisfaction survey was sent out to each patient following consultation. Results Sixty patients were assessed between July 2020 and April 2021. Fiftyseven (95%) were female, and the mean age was 71 years. Following consultation, twenty-one were commenced on zoledronic acid, eighteen on denosumab, three on teriparatide and eighteen no treatments /other. Average time from referral to consultation was 1.75 months. Thirty-four patient satisfaction surveys were returned. Twenty-nine (85%) patients said they would be happy for consultations via telephone in the future, with twenty-five patients (74%) either likely or highly likely to recommend telephone consultation to family or friends. When asked to compare their experience of telephone to faceto- face consultations;twenty (58%) reported being indifferent, four (12%) said their experience was poorer or significantly poorer than face-to-face, and ten (29%) said their experience was better or significantly better. Mean saving on travel expenses was £0-£5 (41% of patients) with four patients (12%) saving £21+. Mean mileage saved was < 5 miles (33% of patients), with seven patients (21%) saving 30+ miles on travel. Conclusion This study reveals that patients, overall, had a positive experience with a pharmacist-led telephone consultation. Such clinics could be implemented across other areas of our rheumatology service, if clinically appropriate;reducing unnecessary patient contact, reducing consultant work load and optimally utilizing skills of the wider multidisciplinary team. Face-to-face consultations still have an essential role where physical examination may be required, or patients have communication barriers. Our sample size was small, and data collection is on-going.

Telemedicine in Patients with Fragility Fractures in the COVID-19 Era

Introduction: The covid19 pandemic has forced the health system to restructure to prevent contagion of our patients. In this context, the members of the Orthogeriatric Group of the Catalan Society of Geriatrics and Gerontology (SCGiG) created a document that collected all the considerations to take into account during the pandemic, based on the current guides and scientific societies, in order to perform a correct follow-up, enhance adherence and prevent future falls. Methods: A bibliographic review was performed, defining the key points in the care of the fractured patient through telemedicine (document is available at http://scgig.cat/docs/gt-orto-covid.pdf). Results: During hospital admission, antiosteoporotic treatment should be started, evaluating indications with the patient and family, to ensure adherence. Diet intake of calcium and vitamin D will be assessed. Discharge report includes evaluation of treatment and monitoring plan, to be useful for liaison nurse, rehabilitator and general practitioner. Six-monthly follow up is recommended for patients with comorbidities, polypharmacy, confusion, fall-risk, or parenteral anti-osteoporotic treatment. With denosumab or teriparatide, annual laboratory tests are recommended, with GFR <20, every six months, at home if possible. Bisphosphonates can be followed by the GP. Zoledronate is not recommended due to delayed administration after surgery, and possibility of transient flu-like simptoms. In the telematic follow-up visit, in patients undergoing zoledronic acid treatment, the new dose can be delayed for 6-12 months, without risk. Consider sequential treatment. Denosumab treatment cannot be delayed, so the patient and family will be trained in self-administration. Support materials from laboratories will be useful to patient and caregivers. Conclusion: Telemedicine is a good strategy for a follow-up, to avoid hospital contact, and starts on hospital admission. Patient and caregivers need access to new technologies and able to understand medical instructions.

Acute respiratory distress syndrome after exposure to carfilzomib (KYPROLIS)

Case Report Introduction Plasma cell leukemia is very rare and an aggressive form of leukemia with a poor prognosis. Interim analysis of a phase II trial (EMN12/HOVON 129) using carfilzomib, lenalidomide, and dexamethasone (KRd) in patients with PCL ≤65 years showed a very good partial response or greater response in 80% with 33% achieving at least a complete response. Carfilzomib (Kyprolis TM) is a proteosome inhibitor and is associated with ARDS and acute respiratory failure in 2% of the cases per FDA package insert. We present a case report of acute respiratory distress syndrome presumed to be potentiated 2/2 to carfilzomib infusion. Case A 58-year-old male with a history of hypertension, recent COVID-19 infection and new diagnosis of untreated Plasma Cell Leukemia presented to our hospital with worsening chest pain, fatigue and dyspnea. Vitals on admission were notable for BP 158/88, HR 101, Tmax 99F and sating 100% on room air. Peripheral blood exam showed WBC: 27.7 x109/L, Hb: 8 gm/dl, platelet: 121000, corrected calcium: 13.3 mg/dl, creatinine: 1.16 mg/dl, total protein:11 g/ dl, uric acid: 8.2 mg/dl, B-2 micro globulin: 5.8 mg/L, Mspike: 5.6 g/dl;IgA lambda type. CT Chest abdomen pelvis revealed diffuse lytic bone lesions. Due to inability to obtain bone marrow biopsy from limited resources after Hurricane Ida and aggressive nature of the cancer, treatment was initiated based off a previous flow cytometry from the peripheral blood which showed 55% plasma cells. Patient started on chemotherapy with Cyclophosphamide, Carfilzomib, and dexamethasone with plans to change to Revlimid from cycle 2. He was also started on fluid hydration and Zometa for hypercalcemia. Patient also received aggressive blood pressure control with metoprolol, amlodipine and IV labetalol as needed. After 2nd dose of Kyprolis, he developed acute hypoxic respiratory distress and was initiated on Bipap. Chest Xray was concerning for fluid overload and/or evolving pneumonia. He was supported with diuretics and broad-spectrum antibiotics;however, he eventually was intubated. He was also started on high dose steroids. Repeat CT chest was negative for thrombosis, but showed extensive bilateral pleural -parenchymal opacities. He had a bronchoalveolar lavage with no obvious infection. Over the next 2 days, patient showed improvement and eventually self-extubated. After his recovery, we continued chemotherapy with Kyprolis and he has tolerated it without issues. Discussion The etiology of ARDS is likely multifactorial, however Kyprolis may have played a major role in his decompensation mainly due to the timing and known side effects of the medication. Based on a study from 2018, only 5 case reports of Kyprolis-associated non-infectious progressive lung injury were found at that time. Clinicians should be mindful of Kyprolis induced lung injury and emphasize the need for tight blood pressure control and careful administration of intravenous fluids to decrease the possibility of lung injury.

Utilizing HealthTree ® Cure Hub's Real-World Data to Assess Treatment Management of Patients with Multiple Myeloma during the COVID-19 Pandemic

Background: Patients with multiple myeloma (MM) are uniquely susceptible to viral and bacterial illnesses, including COVID-19, due to their immunocompromised state, age, treatments, and comorbidities. With the advent of COVID-19, changes to treatment were recommended whenever possible, in order to reduce visits to the clinic. The total effect of these changes on cancer patients with multiple myeloma remains unclear. The aim of this project was to assess treatment management by changes to treatment of patients with MM during the COVID-19 pandemic. Methods: We utilized HealthTree ® Cure Hub for Multiple Myeloma (healthree.org) and invited patients with active MM cancer or precursor conditions to participate in an online survey. We analyzed patient responses to questions regarding their myeloma treatments during the COVID-19 pandemic. Results: 978 MM patients participated in the survey between February to June 2021. Since March 2020, 151 patients (15%) either delayed, postponed, or stopped a myeloma treatment because of COVID-19. The four most common treatments were daratumumab (20%), lenalidomide (15%), stem cell transplant (13%) and zoledronic acid (11%). There were 110 patients that canceled a planned myeloma treatment. Of these patients, 55 (50%) canceled a planned chemotherapy, 15 (14%) canceled a stem cell transplant, 1 (1%) canceled radiation and 39 (35%) indicated other. Eight patients replaced an intravenous or subcutaneous treatment with an oral treatment because of COVID-19. There were 9 patients that started a new myeloma treatment because of COVID-19, the most common being daratumumab (44%), ixazomib (22%), lenalidomide (22%) and carfilzomib (11%). Finally, 15 patients had their lenalidomide (50%), steroid (42%) and carfilzomib (8%) dose changed. Conclusions: Our results show that decision-making regarding treatment changes were made on an individual basis and that patients who required a change in treatment were the minority. Aggregating real-world data can provide evidence that despite the changes, patients with MM still received and efficacious treatment and avoided putting these patients at risk or mortality. Disclosures: Ahlstrom: Bristol Myers Squibb: Other: Patient Advisory;Janssen: Other: Patient Advisory;Pfizer: Other: Patient Advisory;Takeda: Other: Patient Advisory.

Management of bone metastasis and cancer treatment-induced bone loss during the COVID-19 pandemic: An international perspective and recommendations.

Optimum management of patients with cancer during the COVID-19 pandemic has proved extremely challenging. Patients, clinicians and hospital authorities have had to balance the risks to patients of attending hospital, many of whom are especially vulnerable, with the risks of delaying or modifying cancer treatment. Those whose care has been significantly impacted include patients suffering from the effects of cancer on bone, where delivering the usual standard of care for bone support has often not been possible and clinicians have been forced to seek alternative options for adequate management. At a virtual meeting of the Cancer and Bone Society in July 2020, an expert group shared experiences and solutions to this challenge, following which a questionnaire was sent internationally to the symposium's participants, to explore the issues faced and solutions offered. 70 respondents, from 9 countries (majority USA, 39%, followed by UK, 19%) included 50 clinicians, spread across a diverse range of specialties (but with a high proportion, 64%, of medical oncologists) and 20 who classified themselves as non-clinical (solely lab-based). Spread of clinician specialty across tumour types was breast (65%), prostate (27%), followed by renal, myeloma and melanoma. Analysis showed that management of metastatic bone disease in all solid tumour types and myeloma, adjuvant bisphosphonate breast cancer therapy and cancer treatment induced bone loss, was substantially impacted. Respondents reported delays to routine CT scans (58%), standard bone scans (48%) and MRI scans (46%), though emergency scans were less affected. Delays in palliative radiotherapy for bone pain were reported by 31% of respondents with treatments often involving only a single dose without fractionation. Delays to, or cancellation of, prophylactic surgery for bone pain were reported by 35% of respondents. Access to treatments with intravenous bisphosphonates and subcutaneous denosumab was a major problem, mitigated by provision of drug administration at home or in a local clinic, reduced frequency of administration or switching to oral bisphosphonates taken at home. The questionnaire also revealed damaging delays or complete stopping of both clinical and laboratory research. In addition to an analysis of the questionnaire, this paper presents a rationale and recommendations for adaptation of the normal guidelines for protection of bone health during the pandemic.