Secondary Fracture Prevention

• 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;
• 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 favorite activities—and they will be at higher risk of dying prematurely;
• Most importantly, there are actions they can take to reduce their risk, including regular follow-up with their usual health care provider as for any other chronic medical condition.

• At a minimum, take a history of their falls within the last year.
• Minimize use of medications associated with increased fall risk.
• Evaluate patients for conditions associated with an increased fall risk.
• Strongly consider referring patients to physical and/or occupational therapists or a physiatrist for evaluation and interventions to improve impairments in mobility, gait, and balance and to reduce fall risk.

• Do not delay initiation of therapy for bone mineral density (BMD) testing.
• Consider patients' oral health before starting therapy with bisphosphonates or denosumab.

• For patients who have had repair of a hip fracture or are hospitalized for a vertebral fracture:

  • Oral pharmacologic therapy can begin in the hospital and be included in discharge orders.

  • Intravenous and subcutaneous pharmacologic agents may be therapeutic options after the first 2 weeks of the postoperative period. Concerns during this early recovery period include:

    • Hypocalcemia because of factors including vitamin D deficiency or perioperative overhydration.
    • Acute phase reaction of flu-like symptoms after zoledronic acid infusion, particularly in patients who have not previously taken zoledronic acid or other bisphosphonates.
  • If pharmacologic therapy is not provided during hospitalization, then mechanisms should be in place to ensure timely follow-up.

• Reinforcing key messages about osteoporosis and associated fractures;
• Identifying any barriers to treatment plan adherence that arise;
• Assessing the risk of falling;
• Monitoring for adverse treatment effects;
• Evaluating the effectiveness of the treatment plan; and
• Determining whether any changes in treatment should be made, including whether any anti-osteoporosis pharmacotherapy should be changed or discontinued.

• Not to smoke or use tobacco;
• To limit any alcohol intake to a maximum of 2 drinks a day for men and 1 drink a day for women; and
• To exercise regularly (at least 3 times a week), including weight-bearing, muscle strengthening, and balance and postural exercises, depending on their needs and capabilities, preferably supervised by physical therapists or other qualified professionals.

• The risk of osteoporosis-related fractures without pharmacologic therapy; and
• For bisphosphonates and denosumab, the risk of atypical femoral fractures and osteonecrosis of the jaw and how to recognize potential warning signs.

11. First-line pharmacologic therapy options for people aged 65 years or older with a hip or vertebral fracture, include:

• The oral bisphosphonates alendronate and risedronate, which are generally well tolerated, familiar to health care professionals, and available at low cost; and
• Intravenous zoledronic acid and subcutaneous denosumab, if oral bisphosphonates pose difficulties.

For patients at high risk of fracture, particularly those with vertebral fractures, anabolic agents may be useful, although consultation with or referral to a specialist would also be appropriate.

• General recommendations on stopping and restarting anti-osteoporosis drugs are available to individualize treatment for each patient.
• Most published guidelines recommend that the need for therapy with bisphosphonates be reassessed after 3 to 5 years, based on their long half-life in bone and evidence suggesting that the risk of certain rare adverse events may increase with longer duration of treatment.
• Stopping denosumab without starting another antiresorptive drug should be avoided because of the possibility of rapid bone loss and increased fracture risk. Similarly, patients stopping anabolic agents also should be placed on an antiresorptive therapy.