Prevention of secondary fracture in elderly: ASBMR guidelines

The American Society for Bone and Mineral Research (ASBMR) has released guidelines on the prevention of secondary fractures in persons aged 65 years or older with a hip or vertebral fracture.

"Older people who have suffered a hip or vertebral fracture are at extremely high risk of another fracture, yet a majority of them do not receive appropriate treatments following their fracture — these recommendations are intended to help change this unacceptable situation," write the authors.

"The recommendations are not intended to address the clinical management of acute fractures and how best to optimize recovery — for example, how quickly a patient with a hip fracture should proceed to surgery or how best to treat back pain in a patient with vertebral fractures. Such issues are important and potentially could affect the risk of additional fractures but are beyond the scope of this document and this initiative," they suggest.

Key recommendations include:

1. Communicate 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 one to two years;
   
   
   • breaking bones means they may suffer declines in mobility or independence -- for example, have to use a walker, cane, or wheelchair, or move from their home to a residential facility, or stop participating in favourite activities -- and they will be at higher risk of dying prematurely;
   
   
   • most importantly, there are actions they can take to reduce their risk, including regular follow-up with their usual health care provider as for any other chronic medical condition.
   
   
   
   


2. 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.


3. Regularly assess the risk of falling of people aged 65 years or older who have ever had a hip or vertebral fracture.
   
   
   
   • At a minimum, take a history of their falls within the last year.
   
   
   • Minimize the 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, and to reduce fall risk.
   
   
   
   


4. Offer pharmacologic therapy for osteoporosis to people, aged 65 years or older, with a hip or vertebral fracture, to reduce their risk of additional fractures.
   
   
   
   • 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 a 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 and subcutaneous pharmacologic agents may be therapeutic options after the first two weeks of the postoperative period. Concerns during this early recovery period include:
       
       
       
       • Hypocalcemia because of factors including vitamin D deficiency or perioperative overhydration.
       
       
       • Acute phase reaction of flu-like 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.
     
     
     
     
   
   
   
   


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


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


7. Because osteoporosis is a life-long chronic condition, routinely follow and re-evaluate people aged 65 years or older with a hip or vertebral fracture who are being treated for osteoporosis. Purposes include:
   
   
   
   • 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; and
   
   
   • determining whether any changes in treatment should be made, including whether any anti-osteoporosis pharmacotherapy should be changed or discontinued.
   
   
   
   


8. 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.


9. Counsel people aged 65 years or older with a hip or vertebral fracture:
   
   
   
   • not to smoke or use tobacco;
   
   
   • to limit any alcohol intake to a maximum of two drinks a day for men and one
     drink a day for women; and
   
   
   • to exercise regularly (at least three times a week), including weight-bearing, muscle strengthening, and balance and postural exercises, depending on their needs and capabilities, preferably supervised by physical therapists or other qualified professionals.
   
   
   
   


10. 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 risk of osteoporosis-related fractures without pharmacologic therapy; and
    
    
    • for bisphosphonates and denosumab, the risk of atypical femoral fractures (“AFFs”) and osteonecrosis of the jaw (“ONJ”) and how to recognize potential warning signs
    
    
    
    


11. First-line pharmacologic therapy options for people aged 65 years or older with a hip or vertebral fracture include:
    
    
    
    • the oral bisphosphonates alendronate and risedronate, which are generally well-tolerated, familiar to health care professionals, and available at low cost; and
    
    
    • intravenous zoledronic acid and subcutaneous denosumab, if oral bisphosphonates pose difficulties.
    
    
    
    


12. The optimal duration of pharmacologic therapy for people aged 65 years and older with a hip or vertebral fracture is not known.


13. 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 (e.g., hyperparathyroidism, chronic kidney disease).

To read the full guideline click here -- ASBMR Secondary Fracture Prevention Initiative: Consensus Clinical Recommendations and Rationales From a Multistakeholder Coalition