Secondary Prevention After an Osteoporosis-Related Fracture: An Overview

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Key points

  • Having a prior fracture is a major predictor of future fractures.

  • There is strong evidence to support the rationale for postfracture secondary prevention programs.

  • It is believed that a systems approach, with dedicated personnel, bone mineral density (BMD) testing within a program, or both, performs better whereas programs offering only education, awareness, and medication coverage are less effective.

  • Gaps in care still exist despite the improvements demonstrated by postfracture secondary

Burden of fragility fractures

One in 2 women and 1 in 5 men have a fragility (sometimes referred to as a low trauma or osteoporotic) fracture after age 50.1, 2, 3 The risk of fracture in a 1-year period for women over age 50 is higher than the risk of any cardiovascular disease event in that year.4 Having a prior fracture, whether it is a confirmed fragility fracture5, 6, 7 or not,8, 9, 10 is a major predictor of future fracture,5, 6, 7, 8, 9, 10 especially in the first 5 years after the initial fracture.8, 10 According to

The evidence for pharmacologic and nonpharmacologic agents on fracture risk reduction

Evidence gained from rigorous study designs, such as randomized controlled trials, supports the use of both pharmacologic and nonpharmacologic agents in preventing fractures.

The concept of fracture risk is replacing a diagnosis of OP and osteopenia

Since 1994, clinical practice guidelines worldwide have relied on a diagnosis of OP for bone health treatment recommendations.48 A fundamental shift from a diagnosis of OP to absolute fracture risk has become a worldwide phenomenon, with tools such as the Fracture Risk Assessment Tool49 translated and available across 19 countries.50

A recent systematic review identified 12 fracture risk assessment tools for women.51 Between 1 and 31 risk factors were considered in the algorithms of these tools,

Clinical practice guidelines acknowledge the need to intervene in patients who are at risk for future fracture

There has been a movement for clinical practice guidelines to recommend fracture risk assessment in advance of making treatment recommendations,26, 54, 55 with some guidelines recommending pharmacotherapy for patients who are at high risk for future fracture.54

  • According to the 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada, all individuals 50 years of age and older who have had a hip or vertebral fragility fracture or who have had more than 1

The Introduction of Postfracture Secondary Prevention Programs

Despite the knowledge that prior fractures are a major predictor of future fractures,5, 8, 9, 10 it is well documented that fracture patients often do not undergo BMD testing or initiate bone health treatment after a fragility fracture.15, 56, 57, 58, 59, 60 For example, Papaioannou and colleagues57 reported that the proportion of fracture patients who received an OP diagnostic test or physician diagnosis ranged from 1.7% to 50%. Given that approximately half of hip fracture patients have had a

The Scope of Postfracture Secondary Prevention Programs

Postfracture secondary prevention programs are currently established worldwide. Although most programs typically screen all fragility fracture patients over age 50, some have reported data on older adults, ages 65 and older.65, 66 The International Osteoporosis Foundation Capture the Fracture report describes several coordinator-based models of care that have a systematic approach to fragility fracture prevention in Australia, Canada, Singapore, the Netherlands, the United Kingdom, and the

Reduction in Health Care Costs

The effects of postfracture secondary prevention programs on several outcomes have been reported. Some programs have been shown at least cost effective or even cost saving.77, 78, 79, 80

Improved Investigation and Treatment Rates

According to several recent systematic reviews, these programs have had positive effects on BMD testing63, 76 and bone health treatment initiation.63, 76, 81 Little and Eccles81 showed that based on postintervention differences between the intervention and control groups of randomized controlled trials, a

Potential reasons for these gaps in bone health still exist despite postfracture secondary prevention programs

There are opportunities for improvement at several stages in postfracture bone secondary prevention, from identifying patients at risk for future fracture to promoting patients to follow treatment recommendations. For example:

  • Chevalley and colleagues86 reported that 72 patients were given recommendations for medication but only 45 patients were prescribed medication by their family physicians and only 30 patients were still on medication at 6 months.

  • In Sale and colleagues’63 systematic review,

Future research directions in postfracture secondary prevention

Postfracture secondary prevention programs have had considerable positive effects on bone health. Despite these successes, there are several opportunities for improvement:

  • There is a need for consistent information to be relayed to patients beyond the orthopedic environment so that health care providers can promote long-term adherence to treatment recommendations.94

  • Because the concept of fracture risk is relatively new, health care providers need to be aware of revisions to clinical practice

Summary

  • Adults who have had a fragility fracture should be assessed for fracture risk and treated for bone health if indicated.

  • Postfracture secondary prevention programs that aim to improve bone health after a fracture exist worldwide and programs that are coordinator based are endorsed by the International Osteoporosis Foundation.

  • Opportunities to improve the success of these programs include facilitating patients’ understanding of bone health recommendations and the connection between their fracture

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References (119)

  • J.A. Kanis et al.

    Long-term risk of osteoporotic fracture in Malmo

    Osteoporos Int

    (2000)
  • O. Johnell et al.

    Epidemiology of osteoporotic fractures

    Osteoporos Int

    (2005)
  • J.A. Cauley et al.

    Incidence of fractures compared to cardiovascular disease and breast cancer: the women's health intitiative observational study

    Osteoporos Int

    (2008)
  • L. Langsetmo et al.

    Repeat low-trauma fractures occur frequently among men and women who have osteopenic bone mineral density

    J Bone Miner Res

    (2009)
  • J.R. Center et al.

    Risk of subsequent fracture after low-trauma fracture in men and women

    JAMA

    (2007)
  • T.A. van Geel et al.

    Risk factors for clinical fractures among postmenopausal women: a 10-year prospective study

    Menopause Int

    (2007)
  • C.M. Klotzbuecher et al.

    Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis

    J Bone Miner Res

    (2000)
  • T.A. van Geel et al.

    Clinical subsequent fractures cluster in time after first fractures

    Ann Rheum Dis

    (2009)
  • G. Ioannidis et al.

    Relation between fractures and mortality: results from the Canadian Multicentre Osteoporosis Study

    CMAJ

    (2009)
  • I. Sernbo et al.

    Consequences of a hip fracture: a prospective study over 1 year

    Osteoporos Int

    (1993)
  • D. Bliuc et al.

    Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women

    JAMA

    (2009)
  • V. Rabenda et al.

    Low incidence of anti-osteoporosis treatment after hip fracture

    J Bone Joint Surg Am

    (2008)
  • H.C. van der Jagt-Willems et al.

    Mortality and incident vertebral fractures after 3 years of follow-up among geriatric patients

    Osteoporos Int

    (2013)
  • A. Papaioannou et al.

    Lengthy hospitalization associated with vertebral fractures despite control for comorbid conditions

    Osteoporos Int

    (2001)
  • P. Haentjens et al.

    Costs and consequences of hip fracture occurrence in old age: an economic perspective

    Disabil Rehabil

    (2005)
  • O. Johnell et al.

    An estimate of the worldwide prevalence and disability associated with osteoporotic fractures

    Osteoporos Int

    (2006)
  • M. Nikitovic et al.

    Direct health-care costs attributed to hip fractures among seniors: a matched cohort study

    Osteoporos Int

    (2013)
  • M.E. Wiktorowicz et al.

    Economic implications of hip fracture: health service use, institutional care and cost in Canada

    Osteoporos Int

    (2001)
  • G.S. Keene et al.

    Mortality and morbidity after hip fractures

    BMJ

    (1993)
  • X. Song et al.

    Cost burden of second fracture in the US Health Sytem

    Bone

    (2011)
  • A. Papaioannou et al.

    Clinical practice guidelines for the diagnosis and management of osteoporosis in Canada

    Background Technical Report

    (2010)
  • A. Cranney et al.

    IX: summary of meta-analyses of therapies for postmenopausal osteoporosis

    Endocr Rev

    (2002)
  • J.A. Kanis et al.

    European guidance for the diagnosis and management of osteoporosis in postmenopausal women

    Osteoporos Int

    (2013)
  • J.E. Sale et al.

    A post-fracture initiative to improve osteoporosis management in a community hospital in Ontario

    J Bone Joint Surg Am

    (2010)
  • E.R. Bogoch et al.

    Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopaedic environment

    J Bone Joint Surg Am

    (2006)
  • G.A. Wells et al.

    Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women

    Cochrane Database Syst Rev

    (2008)
  • G.A. Wells et al.

    Risedronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women

    Cochrane Database Syst Rev

    (2008)
  • M.R. McClung et al.

    Effects of risedronate on the risk of hip fracture in elderly women

    N Engl J Med

    (2001)
  • K.A. Lyles et al.

    Zoledronic acid and clinical fractures and mortality after hip fracture

    N Engl J Med

    (2007)
  • J.A. Kanis et al.

    Risedronate decreases fracture risk in patients selected solely on the basis of prior vertebral fracture

    Osteoporos Int

    (2005)
  • A.M. Gallagher et al.

    Fracture outcomes related to persistence and compliance with oral bisphosphonates

    J Bone Miner Res

    (2008)
  • J.T. Harrington et al.

    Risedronate rapidly reduces the risk of nonvertebral fractures in women with postmenopausal osteoporosis

    Calcif Tissue Int

    (2004)
  • Y.K. Lee et al.

    Incidence of second hip fracture and compliant use of bisphosphonate

    Osteoporos Int

    (2013)
  • J.J. Carey

    What is a 'failure' of bisphosphonate therapy for osteoporosis?

    Cleve Clin J Med

    (2005)
  • P.N. Sambrook et al.

    Impact of adverse news media on prescriptions for osteoporosis: effect on fractures and mortality

    Med J Aust

    (2010)
  • H.A. Bischoff-Ferrari et al.

    Prevention of nonvertebral factures with oral vitamin D and dose dependency: a meta-analysis of randomized controlled trials

    Arch Intern Med

    (2009)
  • H.A. Bischoff-Ferrari et al.

    Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials

    JAMA

    (2005)
  • S. Boonen et al.

    Need for additional calcium to reduce the risk of hip fracture with vitamin D supplementation: evidence from a comparative metaanalysis of randomized controlled trials

    J Clin Endocrinol Metab

    (2007)
  • R.L. Prentice et al.

    Health risks and benefits from calcium and vitamin D supplementation: women's health initiative clinical trial and cohort study

    Osteoporos Int

    (2013)
  • B. Abrahamsen et al.

    Do calcium plus vitamin D supplements increase cardiovascular risk? Insuffcient evidence is available to support or refute the association

    BMJ

    (2011)
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