Can we properly manage osteoporotic fractures?

Introduction

Osteoporotic fractures can be caused even by minimal energy. However, the consequences of these fractures can be very significant for the patient, with many individuals experiencing reduced physical fitness, impaired quality of life, or cognitive decline after such fractures. At the same time, these difficulties lead to an increase in healthcare expenditures and a greater need for long-term care for affected patients.

International data shows that only a small proportion of patients at high risk of osteoporotic fractures receive appropriate anti-osteoporotic therapy, including those with a history of osteoporotic fracture. Current guidelines recommend that all older patients, especially postmenopausal women, should be offered a plan for managing osteoporosis after a low-energy fracture. According to current knowledge, osteoporosis treatment should start very soon after the fracture.

Global Call to Action: The 4 Pillars of Fracture Management

Current recommendations emphasize that it is suitable not to focus solely on acute fracture management but to adopt a comprehensive solution. The Global Call to Action initiative speaks about four pillars that are significant in treating osteoporosis in older individuals after osteoporotic fractures:

1. Acute Care: Multidisciplinary care of the patient immediately after the fracture.
2. Rehabilitation: Setting an appropriate rehabilitation program to restore functional status, achieve independence, and improve the quality of life, starting rehabilitation as soon as possible.
3. Secondary Prevention: Comprehensive secondary prevention after each osteoporotic fracture, assessing the risk of further falls, and evaluating bone health.
4. National Strategy: Creation of multidisciplinary national initiatives that ensure adherence to the above points.

Algorithm for Managing Osteoporotic Fractures

For all patients who are treated in the hospital after a fracture from a low-energy injury, a multidisciplinary approach that includes comprehensive medical care, functional and psychological assessment, and suitable preoperative preparation is beneficial. Laboratory tests that assess the current state of the patient and play a role in selecting adequate therapy are also essential.

British and Egyptian authors in their recent work, based on Egyptian guidelines for osteoporosis management, created an algorithm for managing osteoporotic fractures:

• Acute Care – multidisciplinary care in the acute stage.
• Post-fracture patient care:
  • rehabilitation
  • assessment of fall risk
  • evaluation of sarcopenia
  • evaluation of functional impairment
  • assessment of the risk of further fractures
  • bone densitometry
  • optimization of administered medication
• Perform suitable laboratory tests:
  • bone metabolism markers – calcium, phosphates, bone alkaline phosphatase, vitamin D
  • renal function – estimated glomerular filtration rate (eGFR)
  • mineralogram
  • liver function
  • IgA and anti-tissue transglutaminase antibodies in case of suspected celiac disease
  • CRP and erythrocyte sedimentation rate
  • complete blood count
  • protein electrophoresis
  • endocrine function – TSH, HbA_1c
  • hormones – testosterone, prolactin
• Initiation of appropriate therapy within 1−2 weeks after the fracture.

Within rehabilitation and fall prevention, the following procedure is recommended:

• Identify frail patients at risk of falls.
• Muscle strength and balance training for individuals at low to moderate fall risk.
• Multifactorial interventions for individuals at high fall risk.
• Assessment of patient condition progress and response to chosen therapy.
• Treating sarcopenia by restoring functional abilities, independence, and quality of life.

Pharmacotherapy of Osteoporosis

In osteoporosis therapy, we distinguish between two main groups of medications: Antiresorptive therapy commonly involves bisphosphonates and denosumab. Anabolic therapy involves administering teriparatide or romosozumab.

According to the above algorithm, appropriate pharmacotherapy should start within 1−2 weeks after the fracture. The choice of therapy depends on renal function values (based on eGFR) and the risk of further fractures:

• eGFR ≥ 30 ml/min/1.73 m² – need to assess the risk of further fractures:
  • very high fracture risk – initiation of anabolic therapy followed by antiresorptive therapy
  • high fracture risk – oral bisphosphonates treatment; if intolerant, IV zoledronate or SC denosumab can be administered
• eGFR < 30 ml/min/1.73 m² – denosumab treatment

When administering anti-osteoporotic therapy, attention should be paid to the contraindications of each modality. Anabolic therapy is contraindicated in patients with severe renal impairment, hypercalcemia, hyperparathyroidism, Paget's disease, bone malignancies or metastases, and post-radiotherapy. Oral bisphosphonates are contraindicated in gastric and esophageal diseases, dysphagia, and the inability to stand or sit upright for 30−60 minutes.

Before starting bisphosphonate or denosumab therapy, a preventive dental examination is recommended. Before denosumab initiation, it is also advised to check serum calcium levels and vitamin D amounts, and ensure their adequate supplementation during the therapy.

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Source: El Miedany Y., Toth M., Elwakil W., Saber S. Post-fracture care program: pharmacological treatment of osteoporosis in older adults with fragility fractures. Curr Osteoporos Rep 2023 Aug; 21 (4): 472−484, doi: 10.1007/s11914-023-00791-w.