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Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition

Conley RB1Adib G2Adler RA3Åkesson KE4Alexander IM5Amenta KC6Blank RD7,8Brox WT9Carmody EE10Chapman-Novakofski K11Clarke BL12Cody KM13Cooper C14Crandall CJ15Dirschl DR16Eagen TJ17Elderkin AL18Fujita M19Greenspan SL20Halbout P21Hochberg MC22Javaid M23Jeray KJ24Kearns AE12King T25Koinis TF26Koontz JS27,28Kužma M29Lindsey C30Lorentzon M31,32,33Lyritis GP34Michaud LB35Miciano A36Morin SN37Mujahid N38Napoli N39,40Olenginski TP41Puzas JE10Rizou S34Rosen CJ42,43Saag K44Thompson E45Tosi LL46Tracer H47Khosla S12Kiel DP48.

J Orthop Trauma. 2020 Apr;34(4):e125-e141. doi: 10.1097/BOT.0000000000001743.

Abstract

Osteoporosis-related fractures are undertreated, due in part to misinformation about recommended approaches to patient care and discrepancies among treatment guidelines. To help bridge this gap and improve patient outcomes, the American Society for Bone and Mineral Research assembled a multistakeholder coalition to develop clinical recommendations for the optimal prevention of secondary fractureamong people aged 65 years and older with a hip or vertebral fracture. The coalition developed 13 recommendations (7 primary and 6 secondary) strongly supported by the empirical literature. The coalition recommends increased communication with patients regarding fracture risk, mortality and morbidity outcomes, and fracture risk reduction. Risk assessment (including fall history) should occur at regular intervals with referral to physical and/or occupational therapy as appropriate. Oral, intravenous, andsubcutaneous pharmacotherapies are efficaciousandcanreduce risk of future fracture.Patientsneededucation,however, about thebenefitsandrisks of both treatment and not receiving treatment. Oral bisphosphonates alendronate and risedronate are first-line options and are generally well tolerated; otherwise, intravenous zoledronic acid and subcutaneous denosumab can be considered. Anabolic agents are expensive butmay be beneficial for selected patients at high risk.Optimal duration of pharmacotherapy is unknown but because the risk for second fractures is highest in the earlypost-fractureperiod,prompt treatment is recommended.Adequate dietary or supplemental vitaminDand calciumintake shouldbe assured. Individuals beingtreatedfor osteoporosis shouldbe reevaluated for fracture risk routinely, includingvia patienteducationabout osteoporosisandfracturesandmonitoringfor adverse treatment effects.Patients shouldbestronglyencouraged to avoid tobacco, consume alcohol inmoderation atmost, and engage in regular exercise and fall prevention strategies. Finally, referral to endocrinologists or other osteoporosis specialists may be warranted for individuals who experience repeated fracture or bone loss and those with complicating comorbidities (eg, hyperparathyroidism, chronic kidney disease).