From the Guidelines
Fragility fractures should be managed with a comprehensive approach, including calcium and vitamin D supplementation, anti-resorptive medications such as alendronate, risedronate, or zoledronic acid, and anabolic agents like teriparatide or romosozumab for high-risk patients, as recommended by recent guidelines 1, 2, 3.
Management of Fragility Fractures
The management of fragility fractures involves a multifaceted approach to prevent further bone deterioration and additional fractures.
- A comprehensive fracture risk assessment, including bone mineral density testing (DEXA scan) and evaluation of risk factors, is essential to guide treatment decisions.
- First-line treatment includes calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) supplementation, along with an anti-resorptive medication such as alendronate (70 mg weekly), risedronate (35 mg weekly), or zoledronic acid (5 mg IV annually) 4, 5.
- For high-risk patients, anabolic agents like teriparatide (20 mcg subcutaneously daily) or romosozumab (210 mg subcutaneously monthly) may be appropriate, as they have been shown to reduce the risk of vertebral, non-vertebral, and hip fractures 1.
- Treatment duration typically ranges from 3-5 years for bisphosphonates, with reassessment afterward to evaluate the need for continued treatment 5.
- Fall prevention strategies, including home safety evaluation, balance training, and review of medications that may increase fall risk, are crucial to reduce the risk of subsequent fractures.
- Weight-bearing exercise should be incorporated into the treatment plan to strengthen bones and improve balance.
- Regular monitoring with follow-up DEXA scans every 1-2 years helps assess treatment effectiveness and adjust the treatment plan as needed.
Importance of Prompt Intervention
Fragility fractures significantly increase the risk of subsequent fractures, with a 5-fold increased risk within the first year, making prompt intervention crucial to prevent further bone deterioration and additional fractures 2, 3.
- A recent study published in 2024 emphasizes the importance of prompt evaluation and treatment of individuals with fragility fractures to reduce the risk of future fractures and related morbidity and mortality 2, 3.
- The study highlights the need for a comprehensive approach to managing fragility fractures, including careful review of the fracture history, incorporation of this data in the fracture risk assessment, and consideration of contributing factors for the underlying osteoporosis or an underlying metabolic bone disease.
Recent Guidelines and Recommendations
Recent guidelines and recommendations from reputable organizations, such as the American College of Physicians and the European League Against Rheumatism, emphasize the importance of a comprehensive approach to managing fragility fractures, including pharmacologic treatment, fall prevention strategies, and regular monitoring 4, 5, 1.
- These guidelines recommend the use of anti-resorptive medications, such as alendronate, risedronate, or zoledronic acid, as first-line treatment for individuals with fragility fractures, with anabolic agents like teriparatide or romosozumab considered for high-risk patients.
- The guidelines also emphasize the importance of regular monitoring and reassessment to evaluate the need for continued treatment and adjust the treatment plan as needed.
From the Research
Definition and Risk Factors
- Fragility fractures are a major public health concern, affecting up to one half of women and one third of men after age 50 years 6.
- History of a fragility fracture is among the strongest risk factors for future fracture 6.
- Osteoporosis is a systemic bone disease characterized by low bone mass and bone mineral density, and deterioration of the underlying structure of bone tissue, leading to an increase in bone fragility and an increased risk for fracture 7.
Prevention and Treatment
- Bisphosphonates have been found to be effective in preventing fragility fractures, with zoledronate being the most effective treatment in preventing vertebral fractures 8.
- Teriparatide had the highest risk reduction of fractures, and the highest probability of being ranked first for efficacy 9.
- Denosumab probably reduces the risk of clinical fragility fractures and clinical vertebral fractures, but may make little-to-no difference in the risk of hip fractures among postmenopausal females 10.
- Treatment with bisphosphonates as a class probably reduces the risk of clinical fragility fractures, and may reduce the risk of hip fractures and clinical vertebral fractures 10.
Screening and Diagnosis
- Screening for the primary prevention of fragility fractures among adults aged 40 years and older in primary care may reduce the risk of hip fractures and clinical fragility fractures 10.
- The Fracture Risk Assessment Tool (FRAX) may be well calibrated for the 10-year prediction of hip fractures and clinical fragility fractures 10.
- The Canadian Association of Radiologists and Osteoporosis Canada Risk Assessment (CAROC) tool may be well calibrated to predict a category of risk for 10-year clinical fractures 10.
Treatment Options
- The most commonly used osteoporosis treatments are the bisphosphonates alendronate, risedronate, ibandronate, and zoledronic acid; the selective estrogen receptor modulator (SERM) raloxifene; teriparatide; and strontium ranelate 7.
- Denosumab and bazedoxifene are recent additions to the treatment options for osteoporosis 7.
- Treatment decisions should be based on a balance between benefits and risks of treatment, and should be made on an individual basis, taking into account all measures of treatment effect and risk 7.