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Consensus statement stresses pharmacotherapy after first hip, vertebral fractures
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Older adults who sustain a hip or vertebral fracture should be appropriately evaluated and treated for osteoporosis to reduce the risk for secondary fracture, with clinicians utilizing fracture liaison services and offering pharmacotherapy, according to a consensus statement published in the Journal of Bone and Mineral Research.
“The statement was motivated by a crisis in our field, characterized by a flattening of a decade of falling hip fracture incidence, probably in part because of a failure to treat patients who have already sustained a hip fracture with osteoporosis medications,” Douglas P. Kiel, MD, MPH, professor of medicine at Harvard Medical School and senior scientist and director of the Musculoskeletal Research Center at the Hinda and Arthur Marcus Institute for Aging Research, told Endocrine Today. “The evidence that a fracture results in a very high increased risk for another potentially life-threatening fracture and the availability of effective, FDA-approved medications led our multistakeholder group to develop these recommendations.”
The American Society of Bone and Mineral Research (ASBMR) and the Center for Medical Technology Policy assembled a coalition of stakeholders across the osteoporosis treatment community to address a widening “treatment gap,” specifically targeting adults aged at least 65 years who sustain a hip or vertebral fracture.
“By focusing its clinical recommendations on secondary prevention, the coalition sought not only to unequivocally target high-risk patients, but also to establish a ‘floor’ upon which subsequent treatment strategies could be built,” the researchers wrote.
The coalition developed 13 recommendations, centered on an “overarching principle” that older adults with a hip or vertebral fracture optimally should be managed in the context of a multidisciplinary clinical system that includes case management, such as a fracture liaison service, to ensure patients are appropriately evaluated and treated.
The statements highlights six fundamental recommendations:
- Consistently communicate three simple messages to people aged 65 years or older with a hip or vertebral fracture: Their broken bone likely means they have osteoporosis and are at high risk for breaking more bones, especially over the next 1 to 2 years; breaking bones means they may experience declines in mobility or independence; and there are actions they can take to reduce their risk.
- Ensure that the usual health care provider for an older adult is made aware of the fracture. If unable to determine whether the patient’s usual health care provider has been notified, take action to be sure the communication is made.
- Regularly assess the risk for falls among people aged at least 65 years who have ever had a hip or vertebral fracture. Minimize use of medications associated with increased fall risk, and consider referring patients to physical and/or occupational therapists or a physiatrist for evaluation and interventions to improve impairments in mobility.
- Offer pharmacologic therapy for osteoporosis to people aged 65 years or older with a hip or vertebral fracture to reduce their risk for additional fractures. Do not delay initiation of therapy for BMD testing.
- Initiate a daily supplement of at least 800 IU vitamin D per day for older adults with a hip or vertebral fracture. Initiate a daily calcium supplement for those who are unable to achieve an intake of 1,200 mg per day of calcium from food.
- Routinely follow and reevaluate older adults with a hip or vertebral fracture treated for osteoporosis, identifying any barriers to treatment, assessing fall risk and determining whether any changes in treatment should be made.
The ASBMR Secondary Fracture Prevention Initiative will also launch an action plan to expand existing secondary fracture prevention registries and data collection, expand the use of fracture liaison services and continue the development of pilot programs for preventing secondary fracture for testing in integrated health care delivery systems.
“Our key recommendation for endocrinologists is that patients who have sustained a hip or vertebral fracture have osteoporosis and should be treated with one of multiple FDA-approved medications for fracture prevention,” Kiel said. – by Regina Schaffer
For more information:
Douglas P. Kiel, MD, MPH, can be reached at the Musculoskeletal Research Center, the Hinda and Arthur Marcus Institute for Aging Research at Hebrew SeniorLife, 1200 Centre St., Boston, MA 02131; email: kiel@hsl.harvard.edu.
Disclosures: Kiel reports he has received consultant fees from Solarea Bio. Please see the study for all authors’ relevant financial disclosures.
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