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Prescription drugs associated with fractures rarely reduced after fracture occurs

Nearly 75% of patients who were using at least one medication that increased their fracture risk did not have that drug reduced following a fragility fracture, according to data published in JAMA Internal Medicine.

Jeffrey C. Munson, MD, MSCE, from the Geisel School of Medicine at Dartmouth, and colleagues urged health care providers to take the opportunity of a fragility fracture to modify prescription drug exposure and reduce the likelihood of secondary fractures.

The researchers wrote that identifying those at risk for fractures is urgent, noting that fragility fractures are associated with annual costs of more than $16 billion.

"One clearly defined high-risk population is survivors of a first fragility fracture," they wrote. "Not only are such patients at significantly increased risk of experiencing a second fracture, the incidence is highest in the first 6 months after a first fracture, highlighting the importance of identifying modifiable risk factors and interventions that can be implemented immediately after an index fragility fracture."

The researchers conducted a retrospective cohort study of 168,133 Medicare beneficiaries who suffered a wrist, shoulder or hip fracture. They analyzed prescription fills for various drugs: Those that increase fall risk, those that decrease bone density, those that increase bone density and those with unclear fracture risk mechanism.

Munson and colleagues reported that 77.1% of hip fracture, 74.1% of wrist fracture and 75.9% of shoulder fracture patients had been exposed to a minimum of one nonopiate drug associated with an increased fracture risk within 4 months before the fracture.

About 7% of those patients stopped using the drug following the fracture, but researchers reported that this decrease was mitigated by new patients using the drugs following a fracture.

After a fragility fracture, 80.5% of hip fracture, 74.3% of wrist fracture and 76.9% of shoulder fracture patients were exposed to drugs associated with increase fracture risk.

In addition, bone density–strengthening drugs were used in less than 25% of patients both before and after fracture.

"The use of drugs that can contribute to elevated fracture risk is common among Medicare beneficiaries who experience a fragility fracture, and the fracture event does not consistently lead to a reduction in use of these drugs," they wrote. "This suggests that at least some secondary fragility fractures may be preventable through a more concerted effort to manage high-risk drugs around a primary fracture event."

In an accompanying editorial, Sarah D. Berry, MD, MPH, and Douglas P. Kiel, MD, MPH, both from the Beth Israel Deaconess Medical Center and Harvard Medical School, as well as the Institute for Aging Research at Hebrew SeniorLife, said that the lack of decline in these medications following a facture is "alarming." They also expressed concern over a lack of osteoporosis treatment after a fracture.

"There are obvious barriers to stopping or initiating treatment with medications following a fracture, including the challenges of working with multiple teams across care settings and the priority of managing the acute fracture complications," Berry and Kiel concluded. "Patient preference is also an important factor that may influence medication changes. These data suggest that comprehensive medication reviews are infrequently being performed or acted on following a fracture, setting our patients up for subsequent falls and fractures. We challenge clinicians to work together to reduce the use of drugs associated with falls and fractures and to treat patients with osteoporosis medications to prevent subsequent fractures, whenever possible, in the weeks to months following a fracture." – by Chelsea Frajerman Pardes

Disclosures: Berry receives grant funding from Amgen. Kiel receives grant funding from Merck and Policy Analysis Inc., consulting fees from Merck and royalties from Wolters Kluwer and Spring for publications related to falls. The other authors reported no relevant financial disclosures.