Secondary Fracture Guidelines Urge Action to Stem Treatment Gap

Nancy A. Melville

October 08, 2019

ORLANDO, Florida — New consensus guidelines on the prevention of secondary fractures from a coalition of bone health experts, professional organizations, and patient advocacy groups provide comprehensive recommendations on the course of clinical care after hip or vertebral fracture in people aged 65 years and older, emphasizing treatment, communication, and multidisciplinary care interventions.

This "is very important because for the first time we have this consensus that certain things will work and there can be a more general application of these practices to all of the fracture patients who are otherwise being missed," Bart Clarke, MD, immediate past president of the American Society for Bone and Mineral Research (ASBMR), told Medscape Medical News at the recent ASBMR 2019 Annual Meeting.

The full consensus report was published in the Journal of Bone and Mineral Research to coincide with the conference.

Treatment Gap Widens From "Hardly Prescribed" to "Almost Never"

A driving purpose for the guidelines is evidence of a widening "treatment gap" where many patients who should receive osteoporosis medication following a fracture are either not being offered treatment or are choosing on their own not to take the medications.

Importantly, evidence shows the risk of a subsequent fracture after a first fragility fracture is at least doubled; however, treatment with effective therapies following the first fracture can reduce the risk of a second fracture by 50% to 70%.

In recent years, rates of osteoporosis treatment following a fracture have significantly dropped. One study showed a decline in treatment initiation among patients hospitalized with hip fracture from approximately 10% in 2004 to just over 3% in 2015 (JAMA Netw Open 2018;1:e180826).

"It has gone from hardly prescribed to almost never prescribed," a senior author of the consensus report, Douglas P. Kiel, MD, MPH, director of the Musculoskeletal Research Center in the Hinda and Arthur Marcus Institute for Aging Research at Hebrew SeniorLife and professor of medicine, Harvard Medical School, Boston, Massachusetts, told Medscape Medical News.

Key reasons for the low rates include the fact that "physicians are not aware that the approved medications should be used to prevent second fractures," Kiel explained.

In addition, "Patients move from hospital to rehab and to home, and treatment slips through the cracks."

"Patients and physicians alike don't realize that a hip or vertebral fracture means the patient has osteoporosis and should be treated."

And patients as well as clinicians have also been deterred by reports of rare but serious side effects of osteoporosis medications, particularly bisphosphonates and the risk of atypical femoral fractures and osteonecrosis of the jaw, he said.

Three Key Messages for Patients

In developing the consensus guidelines to address the issue, the coalition focused on the group that has the strongest evidence of benefitting from treatment following a first fracture: people aged 65 and older with hip or vertebral fractures.

The 13 key recommendations, based on a review of existing clinical guidelines and published studies, have a heavy focus on informing clinicians and communicating to patients the strategies to prevent recurrent fractures — and the potential outcomes of failing to do so.

Topping the list is the recommendation that clinicians communicate three key messages to patients with fracture:

  • That 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.

  • That breaking bones means they may suffer declines in mobility or independence — for example, have to use a walker, cane, or wheelchair, or move from their home to a residential facility, or stop participating in their favorite activities — and they will be at higher risk of dying prematurely.

  • And most importantly, there are actions they can take to reduce their risk, including regular follow-up with their usual healthcare provider, as for any chronic medical condition.

Among the coalition's other recommendations are that clinicians make sure the patient's primary care provider is aware of the occurrence of a fracture; the patient's risk of falling is assessed regularly, and pharmacologic therapy is offered to reduce the risk of additional fractures.

Additional advice includes patients take a vitamin D supplement of at least 800 IU/day and calcium supplements are offered for those unable to achieve a calcium intake of 1200 mg/day from food sources.

Although exercise and diet are also important, Kiel noted that when it comes to prevention of a secondary fracture, it's time to turn to more powerful treatments.

"Other approaches to preventing second fractures, such as exercise and diet are important, but not sufficient," he said.

"It would be like telling someone who has had a heart attack to eat healthy and exercise but not take beta blockers or cholesterol-lowering medications," Kiel explained.

Led by the ASBMR, the coalition was made up of 42 organizations ranging from the American Academy of Orthopedic Surgeons and American Association of Clinical Endocrinologists to the American College of Rheumatology, National Institute on Aging, and National Institutes of Arthritis and Musculoskeletal and Skin Diseases, which acted as federal liaisons.

Fraction Liaison Services Central to Improving Care

An "overarching principle" of the consensus guidelines that has gained interest in recent years is that optimal management should occur in the context of a fraction liaison services (FLS) program.

Such a program is a multidisciplinary clinical system that provides many of the services recommended in the consensus guidelines, with specialists facilitating appropriate follow-up and treatment after a fracture.

"FLS programs are cost-effective or cost-saving in several different practice settings, and have been broadly and successfully adopted internationally," the report notes.

FLS programs have been slow to catch on in the United States. But one successful program, at Houston Methodist Hospital, Texas, was described at the ASBMR meeting.

At this institution, as many as 82% of 250 patients in the program were initiated on osteoporosis treatment from 2015-2018 — a striking figure compared with the rate of  3.3% reported in the literature. Only 6.5% were left untreated.

"[To have] 82% of our fragility fracture patients on medication is an extremely high number," senior author Laila Tabatabai, MD, Houston Methodist, told Medscape Medical News.

She reported a refracture rate of less than 2% among the patients, and Tabatabai and colleagues are currently collecting data for comparison with pre-FLS rates.

"I believe our high medication utilization is directly responsible for reducing refracture rate," she stressed.

"There is clearly a huge benefit to patients and significant healthcare savings, so FLS must be prioritized as the US population ages and fragility fractures become increasingly common," she urged.

Several organizations offer assistance in establishing and sustaining FLS programs, including the American Orthopedic Association's Own the Bone and the International Osteoporosis Foundation's Capture the Fracture.

The report was funded by the ASBMR and received no pharmaceutical industry support. Kiel has reported receiving consultant fees from Solarea Bio and grants from the National Dairy Council and Radius Health. Clarke has reported no relevant financial relationships. Tabatabai has disclosed relationships with Amgen, Radius, and Ultragenyx. The full list of author disclosures is listed in the report.

ASBMR 2019 Annual Meeting. Presented September 22, 2019. Abstract 694.

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