Lebanon, NH—A fracture in an older patient should signal the need for a medication review, but that rarely occurs, according to a new study.
An article published recently in JAMA Internal Medicine was based on data analysis of a sample of Medicare beneficiaries who broke a hip, wrist, or shoulder. The study, led by researchers from the Geisel School of Medicine at Dartmouth, notes that fragility fractures in older adults are a substantial source of sickness, death, and healthcare costs and that patients who suffer one are likely to experience another.
For the research, the study team focused on 168,133 community-dwelling Medicare beneficiaries—84.2% female with an average age of 80 and who had survived a common fracture. Using a list of 21 drugs classes divided into three categories—increased risk of fall, decreased bone density, or unclear primary mechanism for increasing fracture risk—the researchers then used Medicare Part D retail pharmacy claims to measure fills for prescriptions associated with increased fracture risk.
Results indicate that about three-quarters of the patients were using at least one nonopiate drug associated with increased fracture risk in the 4 months before their fracture—77.1% of patients with hip fractures, 74.1% with wrist fractures, and 75.9% shoulder fractures.
While about 7% of the patients discontinued that drug after their bone break, those decreases were offset by new users of the drug associated with increased fracture risk, so the overall percentages didn’t change.
At the same time, fewer than a fourth of the patients were receiving drugs to strengthen bone density before and after fracture, according to the report.
Study authors point out that many drugs could have indications that could preclude them from being discontinued after a fracture, and that the magnitude of the risk associated with many prescription drugs remains uncertain among those who survive fractures. Furthermore, they emphasize, how to improve physician prescribing practices after a fracture is not clearly understood.
“The use of drugs that can contribute to elevated fracture risk is common among Medicare beneficiaries who experience a fragility fracture, and the fracture event does not consistently lead to a reduction in use of these drugs,” the researchers explain. “This suggests that at least some secondary fragility fractures may be preventable through a more concerted effort to manage high-risk drugs around a primary fracture event. Additional research is needed to quantify the possible benefits associated with modifying post-fracture drug exposure in this high-risk population.”
A related commentary suggests that prescribers should, at least, conduct a “thoughtful review” to discuss reducing or eliminating medications associated with falls and bone loss whenever possible.
“Most clinicians wouldn’t dispute the importance of medication review for patients following a fracture but the question is who should do it,” suggested Sherry D. Berry, MD, MPH, of Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, who authored the commentary with colleague Douglas P. Kiel, MD. “We challenge all clinicians to work together to reduce the use of drugs linked to falls and fractures and to treat patients with drugs that can prevent subsequent fractures. We also encourage patients who have experienced a fall or fracture to initiate a discussion with their doctors about the risks and benefits of medications associated with falls and bone loss.”
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