ASBMR Urges Bone Treatment for All Seniors With Major Fractures

MONTREAL, QUEBEC — The American Society of Bone and Mineral Research (ASBMR) has issued a set of recommendations to "close the treatment gap" in patients age 65 years and older who have had a hip or spine fracture.

To address the low rate of secondary therapy to treat osteoporosis in older patients who have had one of these major fractures, the society has issued Secondary Fracture Prevention Initiative Clinical Care Recommendations at the American Society for Bone and Mineral Research (ASBMR) 2018 Annual Meeting.

Douglas P. Kiel, MD, MPH, from the Institute for Aging Research, Hebrew SeniorLife, and Harvard Medical School, Boston, Massachusetts, and coalition co-chair, presented the recommendations.

Clinicians treating older patients who have had a major fracture have some catching up to do, he noted, for example, compared with doctors treating patients who have had a heart attack.

Virtually all patients (96%) who have had a heart attack leave the hospital with a prescription for a beta blocker for secondary prevention (JAMA Cardiol. 2016;1:147-155), Kiel said.

In contrast, only 23% of patients receive osteoporosis medication after a broken hip (ASBMR 2015 annual meeting, Abstract MO0350).

Clinicians need to know that "the occurrence of these two types of fractures — hip and vertebral — means the patient needs to be treated," Kiel told Medscape Medical News.

"If we can get to a much higher treated percentage we will have met some of the goals of this whole initiative."

"I'm optimistic" that practice will change, he said, "but we have to do something ...rather than just talk about it." That's why the group is creating an action plan.

"I practice geriatric medicine and take care of the hip fracture patients," Kiel added. Young physicians think a broken hip is " just a chance event. They don't recognize that the bones are fragile and need to be protected. But they give everyone a beta blocker after a heart attack."

The US action plan is "clearly a fantastic initiative," session co-chair Nicholas Harvey, PhD, from the University of Southampton, United Kingdom, told Medscape Medical News. And he hopes that more international societies will collaborate and get involved "to make sure that people do get the treatment they need."

We need to "increase awareness" of the lack of secondary prevention in older people who have a major fracture, Harvey stressed.

Physicians need greater awareness of the low rate of secondary prevention treatment, and patients "often don't appreciate the level of risk that they have."

Patients May Worry About Side Effects

The ASBMR initiative was triggered, Kiel explained, by patient fears about taking bisphosphonates, as described in a 2016 article in the New York Times: "Fearing Drugs' Rare Side Effects, Millions Take Their Chances With Osteoporosis Drugs."

In 2016, the society pledged to intensify efforts to ensure that more patients are screened, diagnosed, and treated for osteoporosis to prevent secondary fractures.

They brought multiple stakeholders together to come to a consensus for an outline of steps needed to improve the low rate of secondary fracture prevention.

The bottom line in this document, Kiel said, is that "patients 65 years of age or older who experience a hip or vertebral fracture should be treated for osteoporosis."

The group came up with 12 recommendations to try to ensure that more of these patients receive osteoporosis therapy.

Five Key Recommendations, Three Simple Messages

Clinicians treating older patients who have had a major fracture need to:

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 to 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 they will be at higher risk for dying prematurely.

- Most importantly, there are actions they can take to reduce their risk.

Make sure that the patient's primary healthcare provider has been/or is informed that their patient has had a hip or spine fracture.
Regularly assess the risk of falling in men and women age 65 years or older who have ever had a hip or vertebral fracture; at a minimum, ask patients about falls in the past year.
Offer pharmacologic therapy for osteoporosis to men and women age 65 years or older who have a hip or vertebral fracture to reduce their risk of additional fractures.
Routinely follow and re-evaluate men and women age 65 years and older who have a hip or vertebral fracture and are being treated for osteoporosis, because osteoporosis is a life-long chronic condition.

Pharmacologic therapy (oral or intravenous) can begin in the hospital and be included in their discharge orders, according to the guideline document, although some practitioners prefer to delay IV zoledronic acid for a few weeks.

"Do not delay initiation of therapy for bone mineral density (BMD) testing," it further advises.

Although BMD testing may be performed to monitor responses to treatment, therapy should be offered regardless of BMD levels.

Consider the patient's oral health before starting therapy with bisphosphonates or denosumab, this secondary prevention initiative states.

Seven Other Recommendations

The patient care initiative also advises clinicians to do the following:

Consider referring the patient to a specialist if secondary causes of the hip or spine fracture need to be ruled out.
Initiate the patient on a vitamin D supplement.
Counsel the patient about smoking, alcohol, exercise, and calcium.
Discuss the benefits and risks of osteoporosis treatment.
Provide first-line therapy with oral bisphosphonates, and if the patient has difficulties with oral bisphosphonates, treat with IV zoledronic acid or SC denosumab. For severe osteoporosis, particularly of the spine, consider treating the patient with anabolic agents or referring them to a specialist.
Individualize stopping and starting osteoporosis therapy for each patient.
Consider referring patients to a specialist if they continue to have fractures or bone loss on osteoporosis treatment.

The recommendations also focus on actions patients can take to reduce their risk of future fractures "that include medication, exercise, nutrition, and reducing their risk of falling,” said Sundeep Khosla, MD, co-chair of the Coalition, from the Mayo Clinic in Rochester, Minnesota, in a statement by the ASBMR.

"The research shows," he said, "that risks for atypical femur fractures [as a side-effect of bisphosphonate therapy] are very rare and the benefits of taking bisphosphonates far outweigh the risks."

An audience member wanted to know if the group had a specific target for the rate of osteoporosis treatment for secondary fractures in older patients with major initial fractures.

Kiel replied that getting treatment rates up from around 20% to around 50% would be a good start.

American Society of Bone and Mineral Research Annual Meeting. ASBMR-IOF-FFN Joint Session: Closing the Treatment Gap. September 28 - October 01, 2018. Montreal, Quebec.

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