Osteoporosis Treatment After Hip Fracture

Abstract

A growing public health concern is that fewer individuals with documented osteoporosis are receiving effective drug treatment to prevent osteoporotic fractures. 1 Evidence of this treatment gap is abundant and comes from multiple countries, health care settings, and demographic populations.Concerns about overtreatment of lower-risk individuals and rare but serious antiresorptive therapy adverse effects have contributed to undertreatment. Fortunately, there is almost universal agreement that individuals with documented hip or vertebral fracture have established osteoporosis, indicating that they are at high risk of future fracture, and appropriate drug therapy should be routinely offered in these settings. Randomized trials have demonstrated that oral and parenteral bisphosphonate therapy following a hip or vertebral fracture substantially reduces subsequent fractures and disabilities, even in the setting of acute hip fracture. For example, the placebocontrolled HORIZON (Health Outcomes and Reduced Incidence With Zoledronic Acid Once Yearly) Recurrent Fracture Trial 2 found that several yearly doses of intravenous zoledronic acid reduced subsequent clinical fracture risk by 35% (95% CI, 16%-50%), and somewhat unexpectedly reduced mortality by 28% (95% CI, 7%-44%). Lyles et al 2 found zoledronic acid reduced fracture risk regardless of pretreatment bone mineral density or disability.Given the clear clinical mandate to treat individuals with a history of hip fracture (regardless of bone mass measurements), early reports of low rates of treatment were disappointing but perhaps understandable given the comorbidities and frailty that often accompany hip fracture. For example, a high-quality study by Solomon et al 3 reported that among a sample of US Medicare or commercially insured patients with hip fracture in 2011, only 21% received effective drug therapy after the fracture.Similar low rates of treatment following hip fracture have been reported in Spain and Korea. 4 Desai et al 5 extend these previous reports by reporting post-hip fracture treatment rates and associated treatment efficacy in a large US population of commercially insured individuals (mean [SD] age, 80.2 [10.8] years; 64 164 [66%] female). The most noteworthy finding from this analysis is that among 97 169 previously untreated patients with hip fracture, rates of effective drug treatment in the 180 days following hip fracture were only 9.8% (95% CI, 9.0%-10.6%) in 2004, and then decreased to 3.3% (95% CI, 2.9%-3.8%) in 2015. Additional analyses found that low treatment rates were even worse in men and were not explained by disproportionate underuse in older or frail patients. These dismal treatment rates from as recent as 2015, despite a wealth of evidence about the markedly elevated fracture risk and the availability of effective and safe treatments, can only be described as a shocking failure to provide adequate care to a high-risk population. Furthermore, hip fractures represent only the tip of the iceberg; timely evaluation and consideration of...

Orthopedic surgeons’ views on the osteoporosis care gap and potential solutions: survey results

“…While these side-effects do occasionally occur with oral bisphosphonates and may also occur with denosumab, they are rare at osteoporosis doses, occurring more often when used as part of chemotherapy. This misperception is thought to have contributed to a decline in the treatment rate of osteoporosis [14]. The potential for pill esophagitis with oral bisphosphonates was also commonly cited and is a legitimate concern in the local population, as gastroesophageal reflux disease is highly prevalent locally and increases the risk of this relatively prevalent side-effect.…”

Fragility fracture identifies patients at imminent risk for subsequent fracture: real-world retrospective database study in Ontario, Canada

“…The secondary fracture prevention gap described here may have been influenced by several factors documented in recent studies including: insufficient communication from the fracture clinic informing family doctors of their patient incurring a fragility fracture and of high fracture risk (if present) [49]; not incorporating initiation of osteoporosis treatment into discharge order sets following hip fracture [50]; deprioritization of osteoporosis management over other chronic diseases in primary care potentially due in part to underestimation of the consequences of fragility fractures on morbidity and mortality in elderly people [51]; lack of urgency around secondary fracture prevention by utilizing 10 year fracture risk instead of imminent fracture risk [7]; the overreliance on densitometric osteoporosis diagnosis thresholds (BMD T-score of ≤ − 2.5) for therapy initiation rather than history of fracture [52,53]; lack of guidance surrounding the benefit of osteoporosis treatment and the risk of rare adverse events from these treatments (ie, atypical femoral fractures and osteonecrosis of the jaw; < 80 per 100,000 person-years) [7,54]; and overestimated concerns of these rare events by other specialties (i.e., dentists concerned with osteonecrosis of the jaw [54,55]). Current efforts are urgently needed to help address the secondary prevention care gap and its contributors, as part of new guidelines development, advocacy measures, and other initiatives (eg, FLS) [11,13,53,54,56].…”

Osteoporosis case ascertainment strategies in European and Asian countries: a comparative review

“…Universally, one of the primary goals in osteoporosis management is adequate case-finding to ensure that patients at risk for fracture receive the appropriate therapies. However, to date, we have not realized optimal osteoporosis identification and management, as numerous studies have shown the low uptake of osteoporosis treatment following a fragility fracture [8][9][10][11]. One key barrier may relate to a continued lack of appreciation of the burden imposed by fragility fractures from all frontsgovernment, physicians, and patients, thereby leading to a lack of financial investment in resources and an under-diagnosis/under-assessment of at-risk patients.…”

“…This applies to all fractures, regardless of the level of aBMD [7]. However, despite acknowledging the negative consequences of fractures, such as reductions in quality of life and higher mortality associated with fracture [5,6] and the efficacy of treatment to reduce risk, osteoporosis remains widely under-diagnosed and undertreated [8][9][10][11].…”