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Drug treatment, screening ineffective in preventing hip fractures
Antiosteoporotic medications and screenings for bone fragility do little to prevent hip fractures among older patients, whereas more effective, nonpharmacologic interventions are often overlooked, according to research in The BMJ.
In a meta-analysis of studies on various antiosteoporotic medications, researchers found that adults most prone to hip fractures do not benefit from bisphosphonate treatment; evidence claiming drug treatments are cost-effective is lacking; and the overdiagnosis of bone fragility can lead to overtreatment and “ignores the psychological burden associated with the disease label.”
“The dominant approach to hip fracture prevention is neither viable as a public health strategy nor cost-effective,” Teppo Järvinen, MD, PhD, of the University of Helsinki, told Endocrine Today. “Pharmacotherapy can achieve, at best, a marginal reduction in hip fractures at the cost of unnecessary psychological harms, serious medical adverse events, and forgone opportunities to have greater impacts on the health of older people. As such, it is an intellectual fallacy we will live to regret.”
Teppo Järvinen
Järvinen and colleagues at other institutions analyzed data from studies on the efficacy of bisphosphonates for the prevention of hip fractures and found that most studies focused on younger adults, despite that most fractures occur in patients older than 80 years.
“Only three studies have been conducted on subjects 80 years of age or older, and none of them found that the medication prevented hip fractures,” Järvinen said in a press release.
The idea of preventing hip fractures with antiosteoporotic medication is fundamentally flawed, according to researchers, because the brittleness of bones does not significantly affect the occurrence of bone fractures among older people.
In addition, a focus on drug treatment often means the nonpharmacologic interventions are overlooked, he said. Researchers highlighted a recent meta-analysis of fall prevention programs that estimated an overall relative reduction of fracture risk of 60% with exercise training.
“The substantive approaches to preventing hip fractures have not changed in nearly 25 years: stop smoking, be active and eat well,” the researcher wrote.
“There are currently 33 randomized controlled trials, as outlined in our paper, and the effect of the ‘optimized to show an effect’ trials is marginal, at best,” Järvinen said. “Most discouragingly, these trials are hampered with fundamental methodological flaws, as highlighted by our risk of bias assessment. So, even under the efficacy “can-it-theoretically-work circumstances,” drug therapy cannot produce a better effect than this.”
More trials are needed with older adults who are at high risk of fracture, he said.
“Rather than resorting to lame arguments that we do have evidence, a trial on those most prone to have fractures ... should be carried out,” Järvinen said. - by Regina Schaffer
Disclosure: The researchers report no relevant financial disclosures.
Perspective
Back to TopIn this paper, the authors conclude that the current approach to preventing hip fracture is not a cost-effective strategy.
Indeed hip fractures are not common, but when they do occur, the effects are devastating and could be fatal. Through these initial efforts in the 1980s and 2000s, some progress was made in highlighting the need to screen and treat high risk individuals. However, despite all the efforts at physician and public education, the majority of patients who develop hip fractures from osteoporosis remain untreated. It is important to remember that these same individuals who develop hip fractures very likely have already suffered and are prone to develop more spine fractures and other non-vertebral fractures. Preventing hip fractures cannot be the isolated target. Therapy directed towards preventing these fractures also significantly reduce the more common osteoporotic fractures that can lead to as much debility.