Secondary Fracture Risk Stays High, Early Risk Is Greater in Men

Marlene Busko

October 08, 2018

MONTREAL — Men and women who had a major osteoporotic fracture — defined as a hip, spine, forearm, or humerus fracture — had a greater risk for this outcome during the next 25 years than their peers who had not had a fracture.

"Strikingly," this retrospective case-control study in the province of Manitoba, Canada, also found that in the first year after a major osteoporotic fracture, whereas women had a 1.8-fold higher risk of having this outcome than other women, men had a 3.3-fold higher risk than other men.

"These results underscore the importance of timely recognition of fracture events, especially in men," said lead author Suzanne Morin, MD, McGill University, Montreal, Quebec, Canada, here at the American Society for Bone and Mineral Research (ASBMR) 2018 Annual Meeting.

This "is the first time that this is shown in a large population" and reinforces what was seen in smaller cohorts, she told Medscape Medical News.

"The baseline risk for fractures in women is higher than for men," Michael Econs, MD, Indiana University, Indianapolis, and past president of the ASMBR, emphasized to Medscape Medical News, "so this study does not indicate that men have higher fracture risk then women."

However, "what is striking" is that "in both men and women a fracture markedly increases the risk of another fracture, but much more so in men."  

Men Had High Risk for Second Fracture in First 3 Years After First

Morin and colleagues aimed to examine the risk for secondary major osteoporotic fractures in men and women over a long period.

They identified 17,721 men and 40,062 women age 50 years and older who had a fracture from 1989 to 2006 in Manitoba, and they matched each of them with three controls of the same age and sex.

Of these, 29,694 individuals had a major osteoporotic fracture (11,028 forearm, 9313 hip, 5799 humerus, and 3554 spine fractures) and were included in the study.

The mean follow-up duration was 9.9 years, with some individuals followed for up to 25 years.

The annual crude rate of a subsequent major osteoporotic fracture per 1000 person-years among cases was 18.5 in men and 29.6 in women.

Men with an initial fracture had a higher risk for a future fracture at different skeletal sites compared with the increased risk among women.  

Table. Risk for Subsequent Fracture During Follow-up by Site and Sexa

Initial Fracture Site Subsequent Major Osteoporotic Fracture in Men, HR (95% CI) Subsequent Major Osteoporotic Fracture in Women, HR (95% CI)
Hip 2.3 (2.0 - 2.7) 1.4 (1.3 - 1.5)
Humerus 3.6 (3.0 - 4.4) 2.0 (1.9 - 2.2)
Spine 2.5 (2.0 - 3.0) 2.3 (2.1 - 2.6)
Forearm 2.4 (2.1 - 2.8) 1.6 (1.5 - 1.7)
All major osteoporotic fracture sites 2.5 (2.3 - 2.7) 1.6 (1.6 - 1.7)
aRisk of cases vs matched controls; follow-up for a maximum of 25 years.

CI = confidence interval; HR = hazard ratio.

 

In men, the risk for a second major fracture was especially high during the first 3 years after their initial fracture and then declined gradually over time.

In women, this risk was only slightly higher initially, and then plateaued.

By 15 years, the risk for a second fracture in men (HR, 1.8) approached that of women (HR, 1.5).

To prevent secondary fracture, "guidelines recommend bone mineral density (BMD) [tests], osteoporosis medication, fall prevention, exercise, and adequate intake of calcium and vitamin D," Morin noted, but the researchers did not have data on these variables for these patients in this study.

'Unacceptable' Not to Treat Fracture Patients to Prevent Another Break

Both Morin and Econs view these results as a "call to action" to improve secondary fracture prevention.

Morin speculated that men likely have a higher risk of a secondary fracture because they have more comorbidities and are frailer at the time of the first fracture."

Moreover, "it is also known that men receive less osteoporosis medications after a first fracture " than women, she added.

The rates of secondary fractures "could be lowered if patients were identified and treated soon after the initial fracture," she stressed. To address the postfracture care gap, Osteoporosis Canada is working to set up Fracture Liaison Services "to ensure rapid identification and management of patients with a recent fracture."

Econs was even more adamant about the need to identify high-risk patients and treat them to prevent a second fracture.

"Women and men [with osteoporosis] need to be treated, and that's not happening now," he said. High-risk patients with osteoporosis either are not being prescribed appropriate medications or stop taking them: "This is unacceptable."

According to Econs, the current study findings "are of great concern and call for more attention to be paid to men who experience fractures."

"What needs to happen is for doctors and their patients to recognize that older men who experience a fracture have a very high risk of having another fracture in the next 3 years that could be devastating" and can mean, for example, that people will lose their mobility and may have to use a cane or walker, or even have to move to a residential facility.

The  ASBMR Secondary Fracture Prevention Initiative coalition has just released clinical recommendations for women and men 65 years or older who experience a hip or vertebral fracture and should be treated for osteoporosis.

Dr Morin has received research grants from Amgen and Merck.

American Society for Bone and Mineral Research (ASBMR) 2018 Annual Meeting.Abstract 1038. Presented September 29, 2018.

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