Secondary Fracture Prevention: Consensus Clinical Recommendations From a Multistakeholder Coalition

Abstract

Osteoporosis-related fractures are undertreated, due in part to misinformation about recommended approaches to patient care and discrepancies among treatment guidelines. To help bridge this gap and improve patient outcomes, the American Society for Bone and Mineral Research assembled a multistakeholder coalition to develop clinical recommendations for the optimal prevention of secondary fracture among people aged 65 years and older with a hip or vertebral fracture. The coalition developed 13 recommendations (7 primary and 6 secondary) strongly supported by the empirical literature. The coalition recommends increased communication with patients regarding fracture risk, mortality and morbidity outcomes, and fracture risk reduction. Risk assessment (including fall history) should occur at regular intervals with referral to physical and/or occupational therapy as appropriate. Oral, intravenous, and subcutaneous pharmacotherapies are efficacious and can reduce risk of future fracture. Patients need education, however, about the benefits and risks of both treatment and not receiving treatment. Oral bisphosphonates alendronate and risedronate are first-line options and are generally well tolerated; otherwise, intravenous zoledronic acid and subcutaneous denosumab can be considered. Anabolic agents are expensive but may be beneficial for selected patients at high risk. Optimal duration of pharmacotherapy is unknown but because the risk for second fractures is highest in the early postfracture period, prompt treatment is recommended. Adequate dietary or supplemental vitamin D and calcium intake should be assured. Individuals being treated for osteoporosis should be re-evaluated for fracture risk routinely, including via patient education about osteoporosis and fractures and monitoring for adverse treatment effects. Patients should be strongly encouraged to avoid tobacco, consume alcohol in moderation at most, and engage in regular exercise and fall prevention strategies. Finally, referral to endocrinologists or other osteoporosis specialists may be warranted for individuals who experience repeated fracture or bone loss and those with complicating comorbidities (e.g., hyperparathyroidism, chronic kidney disease).

SCOPE 2021: a new scorecard for osteoporosis in Europe

“…Moreover, the treatment gap is increasing with time. The under-treatment of osteoporosis globally [228] has led societies such as the International Osteoporosis Foundation and the American Society for Bone and Mineral Research to come together to urgently address this global crisis in the management of osteoporosis [222,229,230]. This contrasts with the situation following myocardial infarction, for which condition a significant care gap has been overcome in the past 15 years: 75% of such individuals now receive beta blockers to help prevent recurrent myocardial infarction [231].…”

Knowledge and Needs of Resident Physicians Regarding Osteoporosis: A Nationwide Survey of Residents

“…Our findings suggest that one potential way to close the "osteoporosis treatment gap" (15,16) is to improve education of resident physicians in the specialties of family medicine, internal medicine, and obstetrics and gynecology, in whose purview osteoporosis diagnosis and management lies.…”

Atypical Femur Fractures: Another Piece to the Puzzle?

“…(2) BPs are generally safe and effective for up to 10 years of continuous therapy. (1)(2)(3) According to recent ASBMR guidelines, BPs should be used as a first-line treatment in patients with recent fragility fractures. (3) However, in the last 15 years, long-term use of BPs has been called in question after reports of atypical femur fractures (AFF) occurring in subjects exposed to BPs.…”

“…(1)(2)(3) According to recent ASBMR guidelines, BPs should be used as a first-line treatment in patients with recent fragility fractures. (3) However, in the last 15 years, long-term use of BPs has been called in question after reports of atypical femur fractures (AFF) occurring in subjects exposed to BPs. (4)(5)(6) An ASBMR task force released standardized criteria for the diagnosis of AFF that should be strictly followed in both research and clinical practice.…”

“…(7) Several mechanisms have been investigated to explain how BPs, in some rare cases, may paradoxically increase bone fragility. (3) In this issue of the Journal of Bone and Mineral Research, Farlay and colleagues analyzed 52 trans-iliac bone biopsies from patients on long-term BP therapy. (8) The authors found that AFF patients had 2.9% higher degree of mineralization of bone (DMB) compared with controls.…”