If pharmacologic therapy is not provided during hospitalization, then mechanisms should be in place to ensure timely follow-up.

Recommended supplements for these patients include ≥800 IU vitamin D daily and calcium supplements if they are unable to achieve an intake of 1200 mg/day of calcium from food sources.

The physician should ensure that the patients fully understand the risk for osteoporosis-related fracture without pharmacologic therapy, but should also be informed about the safety of potential therapies, and particularly the risk for atypical femoral fractures and osteonecrosis of the jaw.

The recommended first-line pharmacologic therapy in this population is oral bisphosphonates (alendronate or risedronate). Intravenous bisphosphonate (zoledronic acid) and denosumab are useful first-line options for patients who have difficulties with oral bisphosphonates. Depending on individual medical circumstances and other factors, particularly for patients with vertebral fractures and at high risk for fracture, the anabolic agents (teriparatide, abaloparatide, and romosozumab) may also be useful front-line therapies

The optimal length of pharmacologic treatment, particularly for bisphosphonates, is not known. Most guidelines recommend reassessment of the need for treatment after 3 to 5 years of therapy. Denosumab and teriparatide should not be discontinued without starting another therapy, as this may lead to significant bone loss, and rapid transition to another therapy is recommended to prevent subsequent increase in the risk for fractures. Denosumab discontinuation should be followed by another antiresorptive treatment. Use of the anabolic drugs teriparatide and abaloparatide is recommended for ≤2 years during a patient’s lifetime, and the use of romosozumab is limited to 1 year.

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Follow-Up

Osteoporosis and fracture are chronic lifelong conditions and require routine follow-up and monitoring. Various sets of clinical guidelines provide the best ways to monitor elderly patients with fracture. The goals of continued monitoring include reinforcing key messages about osteoporosis and fracture, improving treatment compliance, continued assessment of the risk of falling, and assessing treatment efficacy and adverse effects.

Additional Recommendations

As causes of secondary osteoporosis are common, and identifying and addressing these factors could reduce the risk for secondary fracture, consideration should be given to referring elderly patients with a history of a hip or vertebral fracture and presumed secondary causes to the appropriate specialist.

It is also recommended that patients be counseled about smoke cessation and limiting alcohol intake, as these can have an effect on bone health. Furthermore, physical exercise is recommended, especially weight-bearing and strength-training exercise, to improve bone mineral density and decrease the risks for falls.

Primary care providers should take into account the patient’s specific clinical situation and comorbidities, as well as the available resources and experience, in their decision whether to refer elderly patients with a hip or vertebral fracture to an endocrinologist or osteoporosis specialist.

These consensus recommendations are the first step toward global efforts to reduce the burden of secondary osteoporotic fractures.

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Reference

Conley RB, Adib G, Adler Ra, et al. Secondary fracture prevention: consensus clinical recommendations from a multistakeholder coalition [published online September 20, 2019]. J Bone Miner Res. doi:10.1002/jbmr.3877