Management of Osteoporosis Medication after Osteoporotic Fracture

Abstract

The aim of this study was to provide helpful information for use in selection of an appropriate medication after osteoporotic fractures through conduct of a literature review. In addition, a review of the recommendations of several societies for prevention of subsequent fractures was performed and the appropriate choice of medication for treatment of atypical femur fractures was examined. Clinical perspective was obtained and an updated search of literature was conducted across PubMed and MEDLINE and relevant articles were selected. The articles were selected manually according to relevance, and the references for identified articles and reviews were also evaluated for relevance. The following areas are reviewed: Commonly prescribed osteoporosis medications: BPs (bisphosphonates), denosumab, and SERMs (selective estrogen receptor modulators) in antiresorptive medications and recombinant human parathyroid hormone teriparatide, recently approved Romosuzumab in anabolic agents, clinical practice guidelines for the management of osteoporosis, osteoporotic fracture, and atypical femur fracture. Most medications for treatment of osteoporosis do not delay fracture healing and the positive effect of teriparatide on fracture healing has been confirmed. In cases where an osteoporotic fracture is diagnosed, risk assessment should be performed for selection of very high-risk patients in order to prevent subsequent fractures, and administration of anabolic agents is recommended.

Keywords: Clinical practice guideline; Medication review; Osteoporotic fracture.

Fig. 1. Fracture risk according to the FRAX tool in postmenopausal women. The initial risk assessment used the FRAX tool with clinical risk factors alone and without bone mineral density (BMD). Assessment guidelines were based on the 10-year probability of a major osteoporotic fracture (%). The lower assessment threshold (LAT) set by FRAX were based on the 10-year probability (%) of a major osteoporotic fracture equivalent to that in women without clinical risk factors. The upper assessment threshold (UAT) was set at 1.2 times the intervention threshold. A BMD test is recommended for individuals where the probability assessment lies in the orange region. Adapted from the study by Kanis et al. (Osteoporos Int. 2020;31:1-12) under the terms of the Creative Commons Attribution Non-Commercial (CC BY-NC 4.0) license.

Fig. 2. Treatment pathways according to the categorization of fracture risk. The FRAX probability in the red zone indicates very high risk, where an initial course of anabolic treatment followed by antiresorptive therapy may be appropriate. The FRAX probability in the green zone suggests low risk; lifestyle modifications, calcium and vitamin D nutrition, and menopausal hormone treatment should be considered in these cases. The FRAX probability in the intermediate (orange) zone should be followed by bone mineral density (BMD) assessment and recalculation of FRAX probability including femoral neck BMD. After recalculation, the risk may be in the red (very high risk), orange (high risk, which suggests initial antiresorptive therapy) or green (low risk, either in the original green zone or in the original orange zone but below the intervention threshold) zones. Note that patients with a prior fragility fracture are designated at high risk or possibly at very high risk depending on the FRAX probability. Adapted from Kanis et al. (Osteoporos Int. 2020;31:1-12) under the terms of the Creative Commons Attribution Non-Commercial (CC BY-NC 4.0) license.

Fig. 3. Algorithm for the management of postmenopausal osteoporosis. Fracture risk was determined by the FRAX tool with lumbar spine and hip bone mineral density (BMD). Risk categories: (1) low risk: no prior hip or spine fractures, a BMD T-score at the hip and spine both above –1.0, a 10-year hip fracture risk <3%, and 10-year risk of major osteoporotic fractures <20%; (2) moderate risk: no prior hip or spine fractures, a BMD T-score at the hip and spine both above –2.5, and 10-year hip fracture risk <3% or risk of major osteoporotic fractures <20%; (3) high risk: a prior spine or hip fracture, a BMD T-score at the hip or spine of –2.5 or below, 10-year hip fracture risk ≥3%, or risk of major osteoporotic fracture risk ≥20%; and (4) very high risk: multiple spine fractures and a BMD T-score at the hip or spine of –2.5 or below. Adapted from Shoback et al. (J Clin Endocrinol Metab. 2020;105:dgaa048) with permission of Oxford University Press.

Fig. 4. American Association of Clinical Endocrinologists/American College of Endocrinology Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis–2020 update. Adapted from Camacho et al. (Endocr Pract. 2020;26(Suppl 1):1-46) with permission of Elsevier.

Fig. 5. Decision tree with considerations for medical management after atypical femur fracture (AFF). ^aDefinition may vary across countries, e.g., a hip bone mineral density (BMD) T-score ≤–2.5 standard deviation, older age (70-75 years), a recent fragility fracture, other strong risk factors for fracture, or a FRAX fracture risk score that is above country-specific thresholds. ^bSwitching denosumab to teriparatide may result in progressive BMD loss. ^cBe aware that antiresorptive therapy may be needed after stopping denosumab. Adapted from van de Laarschot et al. (J Clin Endocrinol Metab. 2020;105:1682-99) with permission of Oxford University Press.