From the Guidelines
No, you should not delay osteoporosis treatment after a hip fracture, as early intervention is crucial to reduce the risk of subsequent fractures and improve patient outcomes. According to the most recent and highest quality study 1, bisphosphonates and denosumab have been found to reduce hip fracture risk, with a risk ratio of 0.64 and 0.61, respectively. The study also reported a protective effect of bisphosphonates, denosumab, parathyroid hormone receptor agonists, and romosozumab for hip fractures compared with placebo.
Key Considerations
- Treatment should begin as soon as possible, ideally within the first few weeks after fracture repair, to reduce the risk of subsequent fractures.
- First-line medications typically include bisphosphonates such as alendronate (70mg weekly), risedronate (35mg weekly), or zoledronic acid (5mg IV annually).
- For high-risk patients, anabolic agents like teriparatide (20mcg daily subcutaneous injection) or romosozumab (210mg monthly subcutaneous injection for 12 months) may be preferred initially.
- All patients should also take calcium (1000-1200mg daily) and vitamin D (800-1000 IU daily) supplements.
Rationale
The "care gap" that often occurs when treatment is delayed contributes significantly to preventable subsequent fractures. Additionally, the immobility following a fracture accelerates bone loss, making prompt intervention even more important to prevent a cycle of fractures and declining bone health. As noted in the study 1, pharmacological treatment should preferably use drugs that have been demonstrated to reduce the risk of vertebral, non-vertebral, and hip fractures, and should be regularly monitored for tolerance and adherence.
Patient Management
- Early treatment is crucial because fracture risk is highest in the immediate post-fracture period, with approximately 10% of hip fracture patients experiencing a second fracture within the first year.
- A systematic follow-up is advocated, as part of a five-step plan including identifying patients with a recent fracture, inviting them for fracture risk evaluation, differential diagnosis, therapy, and follow-up.
- Risk communication and shared decision making in the care of patients with osteoporosis may have a positive influence on adherence, as noted in the study 1.
From the Research
Osteoporosis Treatment After Hip Fracture
- The aim of treatment in patients at high risk for fractures is to reduce the risk of a first or a subsequent fracture 2.
- Studies have shown that antiresorptive drugs such as bisphosphonates and denosumab can prevent vertebral, nonvertebral, and hip fractures 2, 3, 4, 5.
- Zoledronic acid has been shown to be effective in reducing the risk of hip fractures, with a relative risk reduction of approximately 59% 3.
- A nationwide population study found that anti-osteoporosis treatment after hip fracture surgery was associated with lower all-cause mortality, with a hazard ratio of 0.69 6.
Timing of Osteoporosis Treatment
- There is no evidence to suggest that delaying osteoporosis treatment after a hip fracture is beneficial 2, 3, 6, 4, 5.
- In fact, studies have shown that early treatment with antiresorptive drugs can reduce the risk of subsequent fractures and improve outcomes 3, 6, 4, 5.
- The American Journal of Medicine study found that bisphosphonates can reduce the relative risk of new vertebral fractures in women with postmenopausal osteoporosis, and that efficacy is maintained during long-term treatment 4.
Benefits of Osteoporosis Treatment
- Osteoporosis treatment has been shown to reduce the risk of fractures, including hip fractures 2, 3, 4, 5.
- Treatment has also been associated with lower all-cause mortality after hip fracture surgery 6.
- A systematic review with network meta-analyses found that zoledronic acid seemed the most effective in preventing vertebral fracture, nonvertebral fracture, and any fracture, and that alendronate or zoledronic acid seemed the most effective in preventing hip fracture 5.