Fragility Fractures: Diagnosis and Treatment
TAKE-HOME POINTS
- 3 million people sustain fragility fractures annually, and nearly 30% die within a year of the fracture.
- The incidence of fragility fractures increases in patients with comorbidities such as thyroid disease, diabetes, hypertension, and heart disease.
- The World Health Organization has developed a set of T-core criteria to diagnose osteoporosis in postmenopausal women: a score >–1 is normal; <–1 but >–2.5 signifies osteopenia; <–2.5 denotes osteoporosis; and <–2.5 with fragility fracture indicates severe osteoporosis.
- The Z score, not the T score, should be used to assess osteoporosis in premenopausal women, men <50 years, and children. The Z score is calculated by comparing the patient’s BMD with the mean BMD of their peers of a similar age, race, and gender. Z scores <–2.0 indicate low BMD for chronological age. A Z score > –2.0 is considered within the expected range for age.
- After an initial fragility fracture, the risk for additional ones increases significantly, making treatment of osteoporosis essential. The National Osteoporosis Foundation recommends treating osteoporosis with pharmacotherapy in patients with a high risk for fracture (T score <–2.5) or history of fragility fracture.26
The recommended daily dose for abaloparatide is 80 mcg via subcutaneous injection with calcium and vitamin D supplements.31 Adverse reactions were consistent between abaloparatide and teriparatide, and included hypercalcemia, hypercalciuria, and orthostatic hypotension.30 The use of parathyroid analogs for >2 years is not recommended due to the risk of osteosarcoma.
Denosumab (Prolia) is a monoclonal antibody that stops osteoclastogenesis by blocking the binding of RANKL to RANK.31 It is indicated for patients intolerant to bisphosphonates or with impaired kidney function. Prolia is administered subcutaneously in 60 mg doses every 6 months in men and postmenopausal women with osteoporosis. Prolia is contraindicated in patients with hypersensitivity to any component of the medication, pregnancy, and hypocalcemia.
Selective estrogen receptor modulators (SERMs), such as raloxifene and tamoxifen, can treat osteoporosis effectively in postmenopausal women. Raloxifene is considered the SERM of choice due to the availability of more robust safety and efficacy data. Raloxifene increases BMD while decreasing bone resorption and bone turnover.32 It is also used to reduce breast cancer risk; however, it increases the risk of thromboembolic events and hot flashes. Tamoxifen is not typically used to treat osteoporosis, but women treated for breast cancer with tamoxifen receive some bone protection.
Lastly, calcitonin and strontium ranelate are also options to treat osteoporosis. However, both calcitonin and strontium ranelate have weak effects on BMD. Calcitonin only transiently inhibits osteoclast activity.33 Therefore, medications like bisphosphonates, teriparatide, denosumab, and SERMs are preferred.
A summary of medications used to treat osteoporosis can be found in Table 3.
Table 3. Overview of Common Medications Used in the Treatment and Prevention of Osteoporosis
Medication | Indication | Dosing |
Calcium supplementation | Mild osteoporosis | 1200 mg oral/d |
Vitamin D supplementation | Mild osteoporosis | 800 to 1000 IU oral/d |
Alendronate | Postmenopausal osteoporosis Osteoporosis prevention | 10 mg oral/d 70 mg oral/wk 5 mg/d 35 mg/wk |
Risedronate | Postmenopausal osteoporosis | 5 mg oral/d 35 mg oral/wk 150 mg oral/mo |
Teriparatide (Forteo) | Glucocorticoid-inducted osteoporosis, postmenopausal osteoporosis, men with severe osteoporosis | 600 mcg/2.4 mL subcutaneous/d |
Abaloparatide (Tymlos) | Postmenopausal osteoporosis | 80 mcg subcutaneous/d |
Denosumab (Prolia) | Patients intolerant to bisphosphonates; patients with impaired kidney function. | 60 mg subcutaneous every 6 mo |
Raloxifene | Postmenopausal osteoporosis | 60 mg oral/d |
Tamoxifen | Postmenopausal osteoporosis | 20 mg oral/d |
Calcitonin | Postmenopausal osteoporosis | 100 units intramuscular or subcutaneous/d 200 units (1 spray) intranasal/d |
Strontium ranelate | Postmenopausal osteoporosis Severe osteoporosis in men | 2 g/d dissolved in water, prior to bedtime Not recommended in CrCl <30 mL/min |
Abbreviation: CrCl, creatinine clearance.
CONCLUSION
With a growing aging population, the prevalence of osteoporosis is expected to increase. By 2025, experts estimate that there will be 2 million fractures yearly, costing the United States upwards of $25 billion.34,35 This estimate does not include the cost of lost productivity or disability, which will likely cost billions more.34,35 Understanding risk factors and eliminating medications known to cause decreased BMD are vital. Obtaining a BMD measurement is the rate-limiting step for treatment initiation. Without an appropriate diagnosis, treatment is unlikely. As providers, it us our responsibility to maintain a high level of suspicion of osteoporosis in the elderly and promptly diagnose and treat them.
