Prevention of Secondary Fractures in Elderly With Hip or Vertebral Fracture Clinical Practice Guidelines (2019)

Prevention of Secondary Fractures in Elderly With Hip or Vertebral Fracture Clinical Practice Guidelines (2019)

American Society for Bone and Mineral Research (ASBMR)

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

November 04, 2019

• Guidelines on preventing secondary fractures in persons aged 65 years or older with a hip or vertebral fracture were released on September 20, 2019, by the American Society for Bone and Mineral Research (ASBMR).^[1]

Fundamental Recommendations

Communicate the following three simple messages to people aged 65 years or older with a hip or vertebral fracture (as well as to their family/caregivers) consistently throughout the fracture care and healing process:

• Their broken bone likely means they have osteoporosis and are at high risk for breaking more bones, especially over the next 1-2 years.
• Breaking bones means they may suffer declines in mobility or independence—for example, having to use a walker, cane, or wheelchair, or move from their home to a residential facility, or stop participating in favorite activities—and they will be at higher risk of dying prematurely.
• Most important, there are actions they can take to reduce their risk, including regular follow-up with their usual healthcare provider as for any other chronic medical condition.

Ensure that the usual healthcare provider for a person aged 65 years or older with a hip or vertebral fracture is made aware of the occurrence of the fracture. If unable to determine whether the patient’s usual healthcare provider has been notified, take action to be sure the communication is made.

Regularly assess the risk of falling of people aged 65 years or older who have ever had a hip or vertebral fracture, as follows:

• At a minimum, take a history of their falls within the last year.
• Minimize use of medications associated with increased fall risk.
• Evaluate patients for conditions associated with an increased fall risk.
• Strongly consider referring patients to physical and/or occupational therapists or a physiatrist for evaluation and interventions to improve impairments in mobility, gait, and balance, as well as to reduce fall risk.

Offer pharmacologic therapy for osteoporosis to people aged 65 years or older who have had a hip or vertebral fracture to reduce their risk of additional fractures, as follows:

• Do not delay initiation of therapy for bone mineral density (BMD) testing.
• Consider patients’ oral health before starting therapy with bisphosphonates or denosumab.
• For patients who have had repair of a hip fracture or are hospitalized for a vertebral fracture, oral pharmacologic therapy can begin in the hospital and be included in discharge orders. Intravenous (IV) and subcutaneous (SC) pharmacologic agents may be therapeutic options after the first 2 weeks of the postoperative period. Concerns during this early recovery period include (a) hypocalcemia because of factors including vitamin D deficiency or perioperative overhydration and (b) acute phase reaction of flulike symptoms following zoledronic acid infusion, particularly in patients who have not previously taken zoledronic acid or other bisphosphonates.
• If pharmacologic therapy is not provided during hospitalization, then mechanisms should be in place to ensure timely follow-up.

Initiate a daily supplement of ≥800 IU vitamin D per day for people aged 65 years or older with a hip or vertebral fracture.

Initiate a daily calcium supplement for people aged 65 years or older with a hip or vertebral fracture who are unable to achieve a calcium intake of 1200 mg/day from food sources.

Because osteoporosis is a lifelong chronic condition, routinely follow and reevaluate people aged 65 years or older with a hip or vertebral fracture who are being treated for osteoporosis. Purposes include the following:

• Reinforcing key messages about osteoporosis and associated fractures
• Identifying any barriers to treatment plan adherence that arise
• Assessing the risk of falling
• Monitoring for adverse treatment effects
• Evaluating the effectiveness of the treatment plan
• Determining whether any changes in treatment should be made, including whether any antiosteoporosis pharmacotherapy should be changed or discontinued.

Additional Recommendations

Consider referring people aged 65 years or older with a hip or vertebral fracture who have possible or presumed secondary causes of osteoporosis to the appropriate subspecialist for further evaluation and management.

Counsel people aged 65 years or older with a hip or vertebral fracture to do the following:

• Refrain from smoking or using tobacco.
• Limit any alcohol intake to a maximum of two drinks a day for men and one drink a day for women.
• Exercise regularly (at least three times a week), including weightbearing, muscle-strengthening, and balance and postural exercises, depending on needs and capabilities, preferably under the supervision of physical therapists or other qualified professionals.

When offering pharmacologic therapy for osteoporosis to people aged 65 years or older with a hip or vertebral fracture, discuss the benefits and risks of therapy, including, among other things, the following:

• The risk of osteoporosis-related fractures without pharmacologic therapy
• For bisphosphonates and denosumab, the risk of atypical femoral fractures (AFFs) and osteonecrosis of the jaw (ONJ) and how to recognize potential warning signs

First-line pharmacologic therapy options for people aged 65 years or older with a hip or vertebral fracture include the following:

• Oral bisphosphonates alendronate and risedronate, which are generally well tolerated, familiar to health care professionals, and available at low cost
• If oral bisphosphonates pose difficulties, IV zoledronic acid and SC denosumab

For patients at high risk of fracture, particularly those with vertebral fractures, anabolic agents may be useful, though consultation with or referral to a specialist would also be appropriate.

The optimal duration of pharmacologic therapy for people aged 65 years and older with a hip or vertebral fracture is not known. General recommendations on stopping and restarting antiosteoporosis drugs are available to individualize treatment for each patient:

• Most published guidelines recommend that the need for therapy with bisphosphonates be reassessed after 3-5 years, in view of their long half-life in bone and the evidence suggesting that the risk of certain rare adverse events may increase with longer duration of treatment.
• Stopping denosumab without starting another antiresorptive drug should be avoided, because of the possibility of rapid bone loss and increased fracture risk. Similarly, patients stopping anabolic agents also should be placed on an antiresorptive therapy.

Primary care providers who are treating people aged 65 years and older with a hip or vertebral fracture may want to consider referral to an endocrinologist or osteoporosis specialist for those patients who, while on pharmacotherapy, continue to experience fractures or bone loss without an obvious cause or who have comorbidities or other factors that complicate management (eg, hyperparathyroidism, chronic kidney disease).