Recent fracture ‘addressable risk factor’ for new fracture
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Women who experience a first fragility fracture are at significant risk for experiencing subsequent fractures, particularly in the 2 years after the fracture, according to findings published in the Journal of Bone and Mineral Research.
“Fragility fractures are known to result in major burdens for patients, medical systems and society,” Cesar Libanati, MD, head of medical strategy, bone, at UCB Pharma, told Endocrine Today. “This study provides evidence that any such fracture, and particularly clinical vertebral fractures, can additionally result in a clear and elevated risk of refracture within the 24 months following the initial fracture; commonly referred to as the imminent fracture risk period. The necessity to ensure that these patients undergo rapid recognition and intervention to decrease that risk can no longer be ignored. At present, most people who sustain an osteoporotic fracture do not receive any treatment, despite seeing several doctors at the time of the fracture or during follow-up. This represents a major missed opportunity.”
In a retrospective, observational study, Libanati and colleagues analyzed data from 35,146 women aged 55 to 90 years who experienced an index fragility fracture in 2013, identified from Swedish national registries (mean age at time of index fracture, 74 years). A history of previous fractures, sustained between 2001 and 2012, and osteoporosis treatment were used to characterize “fracture cascade” patterns. Researchers assessed overall cumulative fracture incidence within 12 and 24 months after the index fracture by index fracture type and age group, accounting for the competing risk for death. Women were followed until occurrence of fracture, death or end of study (Dec. 31, 2015).
Predicting risk
Within the cohort, 20.7% of women had a history of osteoporosis treatment at any point before the index fracture, and 10.1% were treated in the 12 months before the index fracture. Wrist and forearm fractures were the most commonly sustained index fracture (28.5%), followed by hip (20.4%), humerus (14.1%) and clinical vertebral (7.9%). More than one-third of women with an index clinical vertebral (37.9%) or hip (38%) fracture had previously sustained at least one fracture.
Among women with any type of index fracture, 2,310 (6.6%) went on to have a subsequent fracture by 12 months, increasing to 3,970 (11.3%) by 24 months. Cumulative incidence of any subsequent fracture at both 12 and 24 months was greatest for those with an index clinical vertebral fracture (10.7% and 17.6%, respectively), followed by an index hip fracture (7.6% and 13.7%, respectively). Among women with a vertebral fracture, a hip fracture was the most common subsequent fracture within both 12 and 24 months.
Across all fracture types, the proportion of women with any previous fracture increased with age; among women aged at least 70 years, 34% to 46% of index hip or clinical vertebral fractures were not their first fractures.
After sustaining an index clinical vertebral fracture, cumulative incidence of a new fracture during 24 months of follow-up was 18%; cumulative incidence of a new fracture was 14% after sustaining an index hip fracture.
“Women with index hip fractures had the highest cumulative mortality in nearly all age groups (up to 31.6% and 46.4% at 12 and 24 months, respectively, for the oldest age group), except for those aged 60 to 69 years, in which cumulative incidence of mortality was highest for those with index clinical vertebral fractures (5.1% and 7.2% at 12 and 24 months, respectively),” the researchers wrote.
Pharmacotherapy recommended
The researchers noted that osteoporosis treatment rates were low among women with (27%) and without (18%) a previous fracture.
“Regardless of the type or number of prior fractures, treatment rates with drugs known to reduce fracture risk are distressingly low,” the researchers wrote. “Health care systems need to rapidly and efficiently integrate robust secondary fracture prevention pathways to ensure fewer patients miss treatment opportunities and therefore reduce the occurrence of subsequent fractures.”
Libanati said that any person who presents for care with a fracture requires no additional testing to be identified as a person at increased risk for additional fractures.
“Additionally, as many therapies are available that can reduce fracture risk, the logical next step is to introduce mechanisms or processes that will ensure they receive the appropriate management and treatment. Research evaluating how to best make this a reality and then confirming the improved outcomes from this strategy would be a welcomed next step.” – by Regina Schaffer
For more information:
Cesar Libanati, MD, can be reached at Allee de la Recherche, 60, 1070 Brussels, Belgium; email: cesar.libanati@ucb.com.
Disclosures: Amgen and UCB Pharma sponsored this study and funded third-party writing assistance. Toth reports he is an employee of and holds stock in UCB Pharma. Please see the study for all other authors’ relevant financial disclosures.
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