Bone health

7 recommendations on secondary fracture prevention: ASBMR

Wednesday, 4 Dec 2019

The American Society for Bone and Mineral Research has released 7 recommendations for prevention of secondary fracture among people aged 65years and older with a hip or vertebral fracture.

The ASBMR said it was focusing on a group where there is underuse of proven osteoporosis prevention therapies and for whom there is uncontroversial evidence of benefit exceeding risks.

It said undertreatment of fractures was likely due to misplaced fears of rare adverse effects of bisphosphonates and mixed message due to discrepancies between guidelines.

A multistakeholder coalition developed seven fundamental clinical recommendations and six additional recommendations:

1. Give 3 key messages to people over 65 years or older with a hip or vertebral fracture:

  • They likely have osteoporosis and are at high risk for breaking more bones, especially over the next 1 to 2 years;
  • Breaking bones means they may suffer declines in mobility or independence;
  • Most importantly, there are actions they can take to reduce their risk, including regular follow-up.

2. Ensure that the usual health care provider is made aware of the fracture.

3. Regularly assess the risk of falling, at a minimum take a history of their falls within the last year. Minimise falls risk from use of medications and co-morbidities.

4. Offer pharmacologic therapy for osteoporosis to reduce their risk of additional fractures. Do not delay initiation of therapy for BMD testing. If pharmacologic therapy is not provided during hospitalisation, 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.

6. Initiate a daily calcium supplement for people who are unable to achieve an intake of 1200 mg/d of calcium from food sources.

7. Because osteoporosis is a life-long chronic condition, routinely follow and re-evaluate people to:

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

A series of six  additional recommendations include advice on smoking cessation and limiting alcohol intake, exercising regularly.

They also suggest first-line drug therapy options to include the oral bisphosphonates alendronate and risedronate, intravenous zoledronic acid and subcutaneous denosumab, if oral bisphosphonates pose difficulties. Anabolic agents may be useful for patients at high risk of fracture, particularly those with vertebral fractures,

They also provide advice on the optimal duration of anti-osteoporosis therapy, suggesting review after three to five years.

A discussion of the benefits and risks of therapy, should the risk of osteoporosis-related fractures without therapy, as well as the risk of atypical femoral fractures and osteonecrosis of the jaw and how to recognise potential warning signs.

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