The American Society for Bone and Mineral Research (ASBMR) has developed clinical recommendations for the prevention of secondary fractures for patients aged 65 years and older after an initial hip or vertebral fracture. The recommendations were published in the Journal of Bone and Mineral Research last month.
Despite advances in the understanding of the pathogenesis and treatment of osteoporosis, many patients who warrant pharmacological treatment for the prevention of fractures are either not being offered treatment or are choosing not to take medications such as bisphosphonates or other osteoporosis drugs. While under-treatment stems from concerns regarding rare side-effects of osteoporosis medications, particularly bisphosphonates, other reasons persist.
“Osteoporosis‐related fractures are undertreated, due in part to misinformation about recommended approaches to patient care and discrepancies among treatment guidelines,” wrote the authors, led by Douglas P. Kiel, M.D., M.P.H., of Harvard Medical School in Boston.
To help bridge this treatment gap and improve patient outcomes, the ASBMR assembled a multistakeholder coalition to focus on patients where there was agreement that the benefits of treatment generally outweighed the risks in people aged 65 years or older with a hip or vertebral fracture. Based on a review of existing clinical guidelines and medical literature, the coalition developed 13 recommendations, seven primary and six secondary, strongly supported by medical evidence.
“An important overarching principle for the recommendations is that people aged 65 years or older with a hip or vertebral fracture optimally should be managed in the context of a multidisciplinary clinical system that includes case management (one example is a fracture liaison service) to assure that they are appropriately evaluated and treated for osteoporosis and risk of future fractures,” the authors wrote.
The fundamental recommendations include the following: increased communication with patients regarding fracture risk, morbidity and mortality outcomes, and fracture risk reduction; ensure that the usual healthcare provider is made aware of the patient’s fracture; regularly assess the patient’s risk of falling, with referral to physical and/or occupational therapy as appropriate; offer pharmacologic therapy for osteoporosis to reduce the risk of additional fractures; initiate a daily supplement of at least 800 IU vitamin D; and initiate a daily calcium supplement for those who are unable to achieve an intake of 1,200 mg per day of calcium from food sources.
“Because osteoporosis is a life-long chronic condition, routinely follow and re-evaluate people aged 65 years or older with a hip or vertebral fracture who are being treated for osteoporosis,” the authors wrote.
The additional recommendations include the following: consider referring patients who may have secondary causes of osteoporosis to the appropriate subspecialist for further evaluation and management; counsel patients not to smoke or use tobacco, to limit any alcohol intake, and to exercise regularly; discuss the benefits and risks of pharmacologic therapy, including the risk of osteoporosis-related fractures without pharmacologic therapy, the risk of atypical femoral fractures and osteonecrosis of the jaw with bisphosphonates and denosumab; oral bisphosphonates alendronate and risedronate are first-line options and are generally well tolerated, otherwise, intravenous zoledronic acid and subcutaneous denosumab can be considered, while anabolic agents may be useful for patients at high risk; the optimal duration of pharmacologic therapy fracture is not known but as the risk for secondary fractures is highest in the early post‐fracture period, prompt treatment is recommended.
“Most published guidelines recommend that the need for therapy with bisphosphonates be reassessed after 3-5 years. Stopping denosumab without starting another antiresorptive drug should be avoided because of the possibility of rapid bone loss and increased fracture risk. Similarly, patients stopping anabolic agents also should be placed on an antiresorptive therapy,” the authors wrote.
Finally, referral to endocrinologists or other osteoporosis specialists may be warranted for patients who experience repeated fracture or bone loss and those with complicating comorbidities.
“These consensus recommendations represent the first step towards global efforts to reduce the burden of secondary osteoporotic fractures with their devastating effects on survival, function, and quality of life,” the authors wrote.
Robert B. Conley Gemma Adib Robert A. Adler, et al. “Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition.” J Bone Miner Res. September 20, 2019. doi: 10.1002/jbmr.3877