From ASBMR2018: Patients 65 Years of Age or Older Who Experience a Hip or Spine Fracture Should Be Treated for Osteoporosis

American Society for Bone and Mineral Research Secondary Fracture Prevention Initiative Coalition releases new recommendations to intensify efforts to increase diagnosis and treatment of high-risk individuals amid drop in use of evidence-based therapies and increase in expected number of hip fractures

A coalition of bone health experts, physicians, specialists, and patient advocacy groups today released their clinical recommendations to tackle the public health crisis in the treatment of osteoporosis and the debilitating and often deadly hip and spine fractures caused by the disease.

The recommendations from the American Society for Bone and Mineral Research Secondary Fracture Prevention Initiative Coalition – more than 40 top U.S. and international bone health experts, health care professional organizations and patient advocacy organizations dedicated to reducing avoidable secondary fractures – were presented at the ASBMR 2018 Annual Meeting in Montréal, the premier global scientific meeting on bone, mineral and musculoskeletal science. The full recommendations and more data about the crisis in osteoporosis treatment are available on the Coalition’s new website: www.secondaryfractures.org.

The Coalition’s recommendations are the first to outline the best course of clinical care for women and men, age 65 years or older, with a hip or vertebral (spine) fracture. They were developed in response to growing evidence of an alarming trend of an increase in the expected number of hip fractures and high-risk osteoporosis patients who need treatment but are either not being prescribed appropriate medications, or if prescribed, are simply not taking them despite research showing their effectiveness in preventing fractures. Recent patient surveys also show that critical information about the connection between osteoporosis and fracture risk is not getting through to patients.

“I think many people are shocked to learn that these conversations are not happening and simple steps not being taken,” says Michael Econs, MD, ASBMR President and Division Chief of the Division of Endocrinology and Metabolism and Professor of Medicine at the Indiana University School of Medicine. “As doctors, it’s our duty to help our patients and their loved ones understand what they can do to prevent another fracture. We must do a better job communicating with them and one another to help rein in this crisis.”

According to a recent survey by the National Osteoporosis Foundation, 96% of postmenopausal women who say they have not been diagnosed with osteoporosis and have experienced a fracture or break were not told by their doctor it could be linked to osteoporosis. The survey also found that one-third of women in the survey with a fracture were not referred for follow-up visits by health care providers.

“Heart attack patients don’t leave the hospital without beta blockers to prevent another one. But every day, patients hospitalized for hip or spine fractures are not receiving treatments that research shows help prevent a second fracture that could lead to disability or death,” says coalition co-chair Douglas P. Kiel, MD, MPH, and past President of ASBMR, who serves as the Director of the Musculoskeletal Research Center at the Institute for Aging Research, Hebrew SeniorLife and a Professor of Medicine at Harvard Medical School. “We’ve joined forces to provide a roadmap to ensure all care givers from orthopedists to primary care doctors, and many other health professionals, understand what they need to be doing to prevent fractures and how they can partner with patients to make informed choices about osteoporosis treatment options.”

The Problem

• Only 23% of elderly patients who suffer a hip fracture receive osteoporosis medication to reduce future fracture risk compared to 96% of heart attack patients who receive beta blockers to prevent a future heart attack.
• The risk of further fractures after a first major osteoporotic fracture is greatest immediately following the first event.
• Recently, a 30-year downward trend in the number of hip fractures in the United States has plateaued, raising concerns that this may be due to doctors and patients not following diagnostic and treatment guidelines.

The Costs: Human and Economic

While osteoporosis is a highly treatable disease, it is on the rise globally and responsible for more than two million fractures in the United States alone. It is also one of the 10 most costly chronic conditions to Medicare.

• Of the 300,000 hip fractures each year in the U.S., one of every two patients never reaches their previous functional capacity.
• One of every four hip fracture patients ends up in a nursing home.
• One of every four hip fracture patients dies within one year.

Barriers to Care

Although there are many reasons for the “gap” in the treatment of osteoporosis, a major factor is physician and patient concerns over the risk of very rare side effects, especially atypical femur fractures (AFFs) related to the use of osteoporosis drugs called bisphosphonates.

“Patients who have suffered hip or vertebral fractures are at very high risk for suffering from serious and life-threatening fractures in the first one to two years after those fractures. These recommendations focus on actions they can take to reduce their risk of future fractures, that include medication, exercise, nutrition, and reducing their risk of falling,” says Sundeep Khosla, MD, co-chair of the coalition and past president of ASBMR, who serves as director of the Center for Clinical and Translational Science at the Mayo Clinic in Rochester, Minn. “The research shows that risks for atypical femur fractures are very rare and the benefits of taking bisphosphonates far outweigh the risks.”

The following top recommendations for clinical care for women and men, age 65 years or older, with a hip or vertebral fracture, were developed by Coalition members through a consensus process.

The ASBMR Secondary Fracture Prevention Initiative Clinical Care Recommendations

An overarching principle for these recommendations is that women and men, age 65 years or older, with a hip or vertebral fracture, optimally should be managed in the context of a multi-disciplinary clinical system that includes case management, such as a fracture liaison service, to assure that they are appropriately evaluated and treated for osteoporosis and risk of future fractures.

1.Communicate three simple messages to patients and their family/caregivers 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, for example, have to use a walker, cane, or wheelchair, or move from their home to a residential facility) and will be at higher risk for dying prematurely;
• most importantly, there are actions they can take to reduce their risk.

2. Ensure that the patient’s primary healthcare provider is made aware of the occurrence of the fracture. If unable to determine whether the patient’s primary healthcare provider has been notified, take action to be sure the communication is made.

3. Regularly assess the risk of falling of women and men, age 65 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 use of medications associated with an increased risk for falls.
• Evaluate patients for conditions associated with an increased risk for falls.
• Strongly consider referring patients to physical and/or occupational therapy or a physiatrist for evaluation and interventions to improve impairments in mobility, gait, and balance, and to reduce the risk for falls.

4. Offer pharmacologic therapy for osteoporosis to women and men, age 65 years or older, with a hip or vertebral fracture, to reduce their risk of additional fractures.

• Pharmacologic therapy (oral or intravenous) can begin in the hospital and be included in their discharge orders, although some practitioners prefer to delay intravenous zoledronic acid for a few weeks.
• Do not delay initiation of therapy for bone mineral density (“BMD”) testing. Although BMD testing may be performed to monitor responses to treatment, therapy should be offered regardless of BMD levels.
• Consider patients’ oral health before starting therapy with bisphosphonates or denosumab.

5. Because osteoporosis is a life-long chronic condition, routinely follow and re-evaluate women and men, age 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 adherence;
• assessing the risk of falling;
• evaluating the effectiveness of the treatment plan;
• monitoring for adverse effects;
• determining whether any changes in treatment should be made, including whether any osteoporosis pharmacotherapy should be changed or discontinued.

“All patients with hip or vertebral fractures need to be told that their broken bone most likely means they have osteoporosis and they are at very high risk for breaking more bones. Our goal is for patients, families, and their health care professionals to understand this and take actions to prevent future fractures,” says Econs.