Guidance on Medications for Fracture Healing Released by Expert Panel
Commentary by: Robert Adler, MD Robert Adler, MD Stuart Silverman, MD, FACP, FACR; Andrea J. Singer, MD, FACP, CCD; Cyrus Cooper, OBE, MA, DM, FRCP, FFPH, FMedSci; Robert F. Gagel, MD; and, Robert Adler, MD
Osteoporosis medications do not have a negative effect on fracture healing and it is safe to start these medications immediately after a vertebral or nonvertebral fracture, according to a consensus report from the International Osteoporosis Foundation (IOF) Fracture Working Group. The report was published online ahead of print in Osteoporosis International.
"There has been little data on the role of osteoporosis medications in fracture healing and as a result there is little consensus or clinical guidance on how soon after fracture medications should be prescribed," explained lead author Professor Stuart Silverman, MD, FACP, FACR, Cedars-Sinai Medical Center and Clinical Professor of Medicine, University of California, Los Angeles (UCLA). "We hope that this consensus report will help to set the scene for both improved patient care and good clinical study design for future research in this area."
"Patients who have fractured are at significantly higher risk of having another fracture, and we must therefore act quickly to reduce the risk of additional debilitating or life-changing fractures," commented Andrea J. Singer, MD, FACP, CCD, Clinical Director, National Osteoporosis Foundation (NOF). "This new guidance helps to address issues surrounding the immediacy of treatment and should encourage clinicians to treat early to reduce the risk of another break," said Dr. Singer, who is Director of Women's Primary Care and Bone Densitometry in the Department of Obstetrics and Gynecology at MedStar Georgetown University Hospital, in Washington, DC.
Consensus Report Development
The International Osteoporosis Foundation (IOF) reviewed existing literature and voted on appropriateness of care for fracture healing. The multidisciplinary panel of experts used the RAND UCLA appropriateness methodology (RUAM) to find agreement on statements and scenarios for the following key issues:
- Effect of osteoporosis medications on fracture healing
- Risk factors for delayed fracture healing
- Clinical and research goals
- Guidelines for future trial design
- Clinical scenarios of fracture healing
The following are the key panel agreements:
- Preventing delayed fracture healing should be a goal of providers treating patients with fractures and should include identifying patients at increased risk of delayed fracture healing as early as possible in order to consider intervention.
- Antiresorptives, such as bisphosphonates may delay fracture healing; however, the risk is low. No evidence for delay in fracture healing was found when injectable bisphosphonates were given in the first 2 weeks after fracture; however, there were theoretical concerns about whether a single injectable bisphosphonate would be bound avidly to the fracture site and therefore, not be taken up at other sites, which would have benefited from therapy.
- Anabolic agents such as teriparatide that enhance osteoblastic bone formation may have a beneficial effect on fracture healing.
- Case reports suggest improvement in fracture healing with anabolic therapy in individuals at high risk of delayed fracture healing; however, these findings need to be confirmed in randomized clinical trials.
- Osteoporosis medications do not have a negative effect on fracture healing, and that it is safe to start osteoporosis medications as soon as possible after both vertebral and nonvertebral fracture. However, the panel agreed that after the occurrence of an atypical femur fracture, bisphosphonate therapy should be stopped. Treatment with an anabolic agent such as teriparatide should be considered to improve healing.
"If appropriately treated, patients who have suffered a first fracture can considerably reduce their risk of future debilitating fractures," commented Professor Cyrus Cooper, Chair of the IOF Committee of Scientific Advisors. "This consensus report provides clinicians with an excellent point of reference on the effects of osteoporosis medications on fracture healing, including when making treatment decisions in regard to patients who are experiencing delayed fracture healing. It is also a valuable blueprint for future clinical studies on the role of osteoporosis medication and fracture healing."
Large, Population-Based Study Confirms Need for Immediate Osteoporosis Treatment Following a First Fracture
The importance of timely treatment for osteoporosis was demonstrated in a recent population-based study demonstrating that one year after a first major osteoporotic fracture, the risk of a second fracture tripled compared with the general study population. The risk factor was doubled even 10 years later. The findings are based on a study of more 118,000 people in Reykjavik, Iceland, and were presented at the World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal Disease held on April 14-17, 2016 in Malaga, Spain.
"This new information makes it more important than ever that physicians and health care providers take immediate steps to evaluate and treat patients who have sustained an osteoporotic fracture," said Robert F. Gagel, MD, in response to the Icelandic study. "At present, only 26% of patients who sustain their first osteoporotic fracture are evaluated and treated, putting large numbers of patients at risk for subsequent life altering and preventable fractures—a travesty we must work to fix," said Dr. Gagel, who is Professor of Medicine at MD Anderson Cancer Center, President of the National Osteoporosis Foundation, and Co-Chair of the National Bone Health Alliance (NBHA).
"These findings support our focus on secondary fracture prevention and closing the 70% to 80% care gap for testing and treatment for patients over the age of 50 who experience a fracture," said Robert Adler, MD, who is Professor of Internal Medicine, Epidemiology and Community Health at Virginia Commonwealth University School of Medicine; Chief, Endocrinology and Metabolism, McGuire Veterans Affairs Medical Center; and NBHA Co-Chair.