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Strong Bones Prevent Fractures

Editor(s): Pearce, Angela N. MS, RN, FNP-C, ONP-C, Trauma/Orthopaedic Nurse Practitioner, Parkland Health and Hospital System, Dallas, TX.

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doi: 10.1097/NOR.0000000000000659
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“We are only as strong as we are united, as weak as we are divided.”

—J. K. Rowling, Harry Potter and the Goblet of Fire (2005)

Angela N. Pearce, MS, RN, FNP-C, ONP-C, Trauma/Orthopaedic Nurse Practitioner, Parkland Health and Hospital System, Dallas, TX.

We have a global crisis in the treatment of osteoporosis. This highly treatable disease is responsible for more than 2 million fractures per year in the United States alone and on the rise globally. Worldwide, osteoporosis causes more than 8.9 million fractures per year.

The disease burden of osteoporosis far exceeds that incurred by noncommunicable diseases; yet, the care gap from this deadly and debilitating disease is staggering and continues to grow (Adler et al., 2016).

Did you know that this year marks 50 years since the seminal discovery of bisphosphonates, a potent class of osteoporosis therapies, and cornerstone of therapy to date? Dual-energy x-ray absorptiometry (DXA) machines became available 35 years ago and densitometry-based definition of osteoporosis was coined 25 years ago. (T scores −2.5 standard deviations below a healthy 25-year-old woman.) FRAX launched 11 years ago to give a 10-year fracture risk for major fractures and hip fractures. Antiresorptive and anabolic bone-building pharmaceuticals are now increasingly available to treat these diagnoses.

Prevention of the second fracture is multifactorial. Patients and the public often have a poor understanding of osteoporosis and the fracture risk and therapies available. Healthcare providers need to stay current on available therapies and find the time to discuss prevention of falls and fracture risk. Healthcare systems need to be willing to support endeavors that prevent fractures and promote healthy lifestyles.

In September 2019, The American Society of Bone Mineral Research coalition of 39 healthcare organizations developed a series of consensus clinical recommendations for secondary fracture prevention (see Table 1). These recommendations pertain to people 65 years or older with hip or vertebral fractures. They are directed to all healthcare professionals who participate in the care of these patients (including, but not limited to, orthopaedic surgeons, rheumatologists, endocrinologists, family physicians and primary care providers, fracture liaison service coordinators, geriatricians, occupational therapists, physical therapists, rehabilitation therapists, emergency department physicians, gynecologists, hospitalists, infusion nurses, internists, neurosurgeons, nurse practitioners, dentists, oral and maxillofacial surgeons, pharmacists, physician assistants, radiologists, registered dietitian nutritionists, and chiropractors).

Table 1. - Summary of Consensus Recommendations
Fundamental Recommendations
1. Communicate three simple messages to people 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 1–2 years.

  • Breaking bones means they may suffer declines in mobility or independence—e.g., have to use a walker, cane, or wheelchair, or move from their home to a residential facility, or stop participating in favorite 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 healthcare provider as for any other chronic medical condition.

2. Ensure that the usual healthcare provider for a person 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 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 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 pharmacological therapy for osteoporosis to people 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 testing.

  • Consider patients' oral health before starting therapy with bisphosphonates or denosumab.

  • For patients who have had repair of a hip fracture or are hospitalized for a vertebral fracture:

    • Oral pharmacological therapy can begin in the hospital and be included in discharge orders.

    • Intravenous and subcutaneous pharmacological agents may be therapeutic options after the first 2 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 after zoledronic acid infusion, particularly in patients who have not previously taken zoledronic acid or other bisphosphonates.

    • If pharmacological 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 65 years or older with a hip or vertebral fracture.
6. Initiate a daily calcium supplement for people 65 years or older with a hip or vertebral fracture who are unable to achieve an intake of 1,200 mg/day of calcium from food sources.
7. Because osteoporosis is a lifelong chronic condition, routinely follow and reevaluate people 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.

Additional Recommendations
8. Consider referring people 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 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 pharmacological therapy for osteoporosis to people 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 pharmacological therapy; and

  • For bisphosphonates and denosumab, the risk of atypical femoral fractures and osteonecrosis of the jaw and how to recognize potential warning signs.

11. First-ine pharmacological therapy options for people 65 years or older with a hip or vertebral fracture include:
  • The oral bisphosphonates alendronate and risedronate, which are generally well-tolerated, familiar to healthcare professionals, and available at low cost; and

  • Intravenous zoledronic acid and subcutaneous denosumab, if oral bisphosphonates pose difficulties.

For patients at high risk of fracture, particularly those with vertebral fractures, anabolic agents may be useful, although consultation with or referral to a specialist would also be appropriate.
12. The optimal duration of pharmacological therapy for people 65 years and older with a hip or vertebral fracture is not known.
  • General recommendations on stopping and restarting anti-osteoporosis drugs are available to individualize treatment of each patient.

  • Most published guidelines recommend that the need for therapy with bisphosphonates be reassessed after 3–5 years, based on their long half life in bone and evidence suggesting that the risk of certain rare adverse events may increase with a longer duration of treatment.

  • Stopping denosumab without starting another antiresorptive drug should be avoided because of the possibility of rapid bone loss and increased fracture risk. Similarly, patients stopping anabolic agents should be placed on an antiresorptive therapy.

13. Primary care providers who are treating people 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).
Reproduced with permission from the American Society for Bone and Mineral Research: Conley, R.B., Adib, G., Adler, R.A., Åkesson, K.E., Alexander, I.M., Amenta, K.C., Blank, R.D., Brox, W.T., Carmody, E.E., Chapman-Novakofski, K., Clarke, B.L., Cody, K.M., Cooper, C., Crandall, C.J., Dirschl, D.R., Eagen, T.J., Elderkin, A.L., Fujita, M., Greenspan, S.L., Halbout, P., Hochberg, M.C., Javaid, M., Jeray, K.J., Kearns, A.E., King, T., Koinis, T.F., Koontz, J.S., Kužma, M., Lindsey, C., Lorentzon, M., Lyritis, G.P., Michaud, L.B., Miciano, A., Morin, S.N., Mujahid, N., Napoli, N., Olenginski, T.P., Puzas, J.E., Rizou, S., Rosen, C.J., Saag, K., Thompson, E., Tosi, L.L., Tracer, H., Khosla, S. and Kiel, D.P. (2020). Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition. Journal of Bone and Mineral Research, 35(1), 36-52. doi: 10.1002/jbmr.3877.

The use of a Fracture Liaison Service ensures that the patient is appropriately evaluated and treated for osteoporosis and promotes the prevention of the second fracture.

We must stop this public health crisis by advocating for our vulnerable patients, provide frontline teaching, and find that “teachable moment” that prevents the second fracture and stops the revolving hospital door of untreated or undertreated osteoporotic fractures.

“Together we can make a difference.”

References

Adler R. A., El-Hajj Fuleihan G., Bauer D. C., Camacho P. M., Clarke B. L., Clines G. A., Compston J. E., Drake M. T., Edwards B. J., Favus M. J., Greenspan S. L., McKinney R. Jr., Pignolo R. J., Sellmeyer D. E. (2016). Managing osteoporosis in patients on long term bisphosphonate treatment: Report of a task force of the American Society for Bone and Mineral Research. Journal of Bone and Mineral Research, 31(1), 16–35.
Conley R. B., Adib G., Adler R. A., Åkesson K. E., Alexander I. M., Amenta K. C., Blank R. D., Brox W. T., Carmody E. E., Chapman-Novakofski K., Clarke B. L., Cody K. M., Cooper C., Crandall C. J., Dirschl D. R., Eagen T. J., Elderkin A. L., Fujita M., Greenspan S. L., Halbout P., Kiel D. P. (2020). Secondary fracture prevention: Consensus clinical recommendations from a multistakeholder coalition. Journal of Bone and Mineral Research, 35(1), 36–52.

Suggested Readings

Compston J. E., McClung M. R., Leslie W. D. (2019). Osteoporosis. The Lancet, 393(10169), 364–376.
Eastell R., Rosen C. J., Black D. M., Cheung A. M., Murad H. M., Shoback D. (2019). Pharmacological management of osteoporosis in postmenopausal women: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 104(5), 1595–1622.
Harvey N. C., McCloskey E. V., Mitchell P. J., Dawson-Hughes B., Pierroz D. D., Reginster J. Y., Rizzoli R., Cooper C., Kanis J. A. (2017). Mind the (treatment) gap: A global perspective on current and future strategies for prevention of fragility fractures. Osteoporosis International, 28(5), 1507–1529.
Kanis J. A., Cooper C., Rizzoli R., Abrahamsen B., Al-Daghri N. M., Brandi M. L., Cannata-Andia J., Cortet B., Dimai H. P., Ferrari S., Hadji P., Harvey N. C., Kraenzlin M., Kurth A., McCloskey E., Minisola S., Thomas T., Reginster J. Y., & European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO). (2017). Identification and management of patients at increased risk for osteoporotic fracture: Outcomes of an ESCEO expert consensus meeting. Osteoporosis International, 28(7), 2023–2034.
© 2020 by National Association of Orthopaedic Nurses