Bisphosphonate Use and the Risk of Subtrochanteric or Femoral Shaft Fractures in Older Women

Park-Wyllie, Laura; Mamdani, Muhammad; Juurlink, David N.; Hawker, Gillian; Gunraj, Nadia; Austin, Peter C.; Whelan, Daniel B.; Weiler, Peter J.; Laupacis, Andreas

doi:10.1001/jama.2011.190

Cited by 385 publications

(260 citation statements)

References 45 publications

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“…(11) Despite the exhaustive nature of our data collection, our study has some limitations. The French Hospital National Discharge Data did not include the medical consumption of treatments related to osteoporosis, and no data was available for outpatients.…”

Section: Discussionmentioning

confidence: 98%

“…(1)(2)(3)(4)(5)(6)(7)(8) However, the increased risk of ST/FS fractures in patients taking bisphosphonates long term has not been clearly established and might be related to fragility fractures. (9)(10)(11)(12) Although the incidence of hip fractures has been well characterized, the incidence of ST/FS fractures has only recently been reported. A few epidemiology studies have looked at the prevalence of femoral fractures, and pointed out that their occurrence in elderly women might result from bone fragility.…”

Section: Introductionmentioning

confidence: 99%

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Subtrochanteric/femoral shaft Versus hip fractures: Incidences and identification of risk factors

Maravic¹,

Ostertag

Cohen‐Solal

2011

Journal of Bone and Mineral Research

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Subtrochanteric and femoral shaft (ST/FS) fractures are now considered to be fragility fractures in osteoporotic patients. Although rare, there is growing evidence of the burden that they constitute. Little is known about the change over time in incidence of ST/FS fractures. We assessed the incidence of ST/FS fractures and the associated risk factors from 2002 to 2009 compared with those of hip fractures. Data were obtained from the French National Database, which includes all hospital discharge codes from acute care facilities. Hospitalizations for primary surgical management of neck/trochanteric (hip) and ST/FS fractures in patients aged above 50 years were selected and described for different age groups. Incidences per million populations were calculated using the estimated French population adjusted for each year, age, and gender. We studied the change for each fracture site. The comorbidity factors related to these fractures were assessed in 2009 using multivariate logistic regression. From 2002 to 2009, the adjusted incidence of hip fractures decreased continuously from 4368 to 3662 in women ( p < 0.0001), and a mild increase from 1476 to 1384 in men ( p < 0.0001) after an initial decrease. In contrast, the incidence of ST/FS increased significantly in both genders (from 353 to 395 in women, from 146 to 159 in men).

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Section: Discussionmentioning

confidence: 98%

Section: Introductionmentioning

confidence: 99%

Subtrochanteric/femoral shaft Versus hip fractures: Incidences and identification of risk factors

Maravic¹,

Ostertag

Cohen‐Solal

2011

Journal of Bone and Mineral Research

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“…(13) In contrast, a Canadian study of elderly women who were hospitalized with a diaphyseal femur fracture found an increased risk in those treated with more than 5 years of bisphosphonates. (14) A serious limitation of these studies is the reliance upon International Classification of Diseases, Ninth Revision (ICD-9) codes only to identify the cases. Spangler and colleagues (15) recently reported that the validity of the ICD-9 codes for identifying fractures in the diaphyseal region of the femur had a specificity of only 36%, mainly because so many were actually trochanteric fractures.…”

Section: Introductionmentioning

confidence: 99%

Incidence of atypical nontraumatic diaphyseal fractures of the femur

Dell

Adams

Greene

et al. 2012

Journal of Bone and Mineral Research

398

278

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Bisphosphonates reduce the rate of osteoporotic fractures in clinical trials and community practice. ''Atypical'' nontraumatic fractures of the diaphyseal (subtrochanteric or shaft) part of the femur have been observed in patients taking bisphosphonates. We calculated the incidence of these fractures within a defined population and examined the incidence rates according to duration of bisphosphonate use. We identified all femur fractures from January 1, 2007 until December 31, 2011 in 1,835,116 patients older than 45 years who were enrolled in the Healthy Bones Program at Kaiser Southern California, an integrated health care provider. Potential atypical fractures were identified by diagnostic or procedure codes and adjudicated by examination of radiographs. Bisphosphonate exposure was derived from internal pharmacy records. The results showed that 142 patients had atypical fractures; of these, 128 had bisphosphonate exposure. There was no significant correlation between duration of use (5.5 AE 3.4 years) and age (69.3 AE 8.6 years) or bone density (T-score À2.1 AE 1.0). There were 188,814 patients who had used bisphosphonates. The age-adjusted incidence rates for an atypical fracture were 1.78/100,000/year (95% confidence interval [CI], 1.5-2.0) with exposure from 0.1 to 1.9 years, and increased to 113.1/100,000/year (95% CI, 69.3-156.8) with exposure from 8 to 9.9 years. We conclude that the incidence of atypical fractures of the femur increases with longer duration of bisphosphonate use. The rate is much lower than the expected rate of devastating hip fractures in elderly osteoporotic patients. Patients at risk for osteoporotic fractures should not be discouraged from initiating bisphosphonates, because clinical trials have documented that these medicines can substantially reduce the incidence of typical hip fractures. The increased risk of atypical fractures should be taken into consideration when continuing bisphosphonates beyond 5 years. ß

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“…Although studies with long-term drug-dispensing information exist, they have had to rely on diagnosis codes, so atypical femur fractures could not be distinguished from other subtrochanteric or diaphyseal femur fractures. (1,2) The former type of study may show correct incidence rates yet provide odds ratios (OR) that are too high because of the undercapture of past drug exposure, whereas the latter type of study will provide incidence rates that are too high and odds ratios that are too low because they include fractures that may not be atypical.…”

mentioning

confidence: 99%

Atypical femur fractures: Refining the clinical picture

Abrahamsen

2012

Journal of Bone and Mineral Research

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Bisphosphonate Use and the Risk of Subtrochanteric or Femoral Shaft Fractures in Older Women

Abstract: Among older women, treatment with a bisphosphonate for more than 5 years was associated with an increased risk of subtrochanteric or femoral shaft fractures; however, the absolute risk of these fractures is low.

Cited by 385 publications

References 45 publications

Subtrochanteric/femoral shaft Versus hip fractures: Incidences and identification of risk factors

Subtrochanteric/femoral shaft Versus hip fractures: Incidences and identification of risk factors

Incidence of atypical nontraumatic diaphyseal fractures of the femur

Atypical femur fractures: Refining the clinical picture

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