Boston—Osteoporosis-related fractures tend to be undertreated. The reasons for that include confusion about the best approaches and lack of clarity in treatment guidelines, according to a recent report.

To improve treatment, the American Society for Bone and Mineral Research (ASBMR) put together a coalition of experts to develop clinical recommendations for the optimal prevention of secondary fracture among people aged 65 years and older with a hip or vertebral fracture. The guidelines were published recently in the Journal of Bone & Mineral Research.

A key element in the 13 evidence-based recommendations—seven primary and six secondary—is greater use of pharmaceuticals to prevent fractures.

“The value of our secondary fracture prevention efforts is that it will be used to initiate an action plan to improve the current practice of not treating many patients who have sustained a hip or vertebral fracture,” explained senior author 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 at Harvard Medical School. “We are pursuing a multitude of activities such as improving awareness, educating physicians in practice, creating national fracture registries, and meeting with CMS to set financial and quality of care-related reimbursement to care for older adults who have sustained a fracture.”

Specifically, the document states, “Oral, intravenous, and subcutaneous pharmacotherapies are efficacious and can reduce risk of future fracture,” but cautions, “Patients need education, however, about the benefits and risks of both treatment and not receiving treatment.”

Here is what the coalition recommends:
• Oral bisphosphonates alendronate and risedronate are first-line options and are generally well tolerated; otherwise, IV zoledronic acid and SC denosumab may be considered.
• Anabolic agents are expensive but may be beneficial for selected patients at high risk.
• Optimal duration of pharmacotherapy is unknown, but because the risk of second fractures is highest in the early postfracture period, prompt treatment is recommended.
• Adequate dietary or supplemental vitamin D and calcium intake should be assured.
• Patients being treated for osteoporosis should be reevaluated for fracture risk routinely, including via patient education about osteoporosis and fractures and monitoring for adverse treatment effects.

In addition, the panel advises pharmacists and other healthcare professionals to communicate more with patients regarding fracture risk, mortality, and morbidity outcomes and about fracture-risk reduction.

The guidelines state that risk assessment, including fall history, should occur regularly and that appropriate referrals to physical and/or occupational therapy should be initiated. Patients should be strongly encouraged to avoid tobacco, consume alcohol in moderation at most, and engage in regular exercise and fall-prevention strategies, the document further notes.

For patients who have repeated fracture or bone loss and those with complicating comorbidities such as hyperparathyroidism or chronic kidney disease, referral to an endocrinologist or other osteoporosis specialist is advised, the panel says.

The coalition, formed by the Center for Medical Technology Policy at the behest of ASBMR, included representatives from 42 professional organizations from the United States and abroad, including the American College of Physicians, American Association of Nurse Practitioners, American Geriatrics Society, and International Osteoporosis Foundation.

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