The number of older people with fractures related to osteoporosis is huge. The National Osteoporosis Foundation (NOF) estimates that 1 of every 2 women and 1 of every 4 men 50 years or older will experience a fracture. Think about it. That’s 50% of women and 25% of men. Many of these fractures will occur as the result of a low trauma event, such as a fall from a standing height. They are considered fragility fractures because our big bones (hip, shoulder, and spine) are not supposed to break when we fall.
“the annual number of osteoporotic fractures that occur exceeds the incidence of heart attack, stroke, and breast cancer combined.”
Despite the magnitude of the problem, we have yet to take this disease as seriously as those other conditions. Perhaps, it is because we associate the condition with fragile little old ladies who gradually shrink and bend over. Most of us don’t think of it as a killer or a cause of major disability. But that is not correct.
Second fractures are common, particularly, for individuals who sustain a hip or vertebral fracture. And, the disability after a fragility fracture can be significant. Up to 85% of older adults who have fallen experience a syndrome known as “fear of falling” that causes them to alter their gait and become less active. Hip fracture, in particular, is associated with a significant increase in the first year after the fracture.
So, it is pretty disturbing to read the results of a recent study, “Patterns of Prescription Drug Use Before and After Fragility Fracture” published in the August 22 online issue of JAMA Internal Medicine. It turns out that not only are we failing to reduce the overall use of drugs that are associated with fractures, but only a fraction of the number of people who are eligible for prescriptions for bone-strengthening drugs are actually getting them.
Drugs that increase the risk of fracture
The researchers, led by Jeffrey Munson MD from the Department of Medicine at Dartmouth, looked at 2007-2011 data from Medicare beneficiaries to determine whether their prescriptions for drugs known to increase fracture risk were changed after they sustained their fracture. Here is what they found:
- Three-fourth of the 168,133 beneficiaries who survived a fragility fracture were using a risky drug at the time of the fracture
- More than half of the patients were taking at least one drug that increases fall risk prior to their fracture; slightly less than half were taking at least 1 drug that decreases bone density
- Although some of the drugs were stopped in a small number of people after the fracture, about the same number of risky new drugs were prescribed
Drugs that increase the risk of fracture fall into three categories:
1. Drugs that increase the risk of falls, such as opiates (used by 35% of the cohort), selective serotonin reuptake inhibitors (SSRIs) (by 26%), thiazide diuretics (by 23%), and nonbenzodiazipine sedative hypnotics (by 11%).
2. Drugs that decrease bone density, including proton pump inhibitors (used by 26% of the cohort), anticonvulsants (by 9%), and oral or inhaled glucocorticoids (by 17%).
3. Drugs that are associated with fractures, but the mechanism is unclear. These drugs included loop diuretics and antipsychotics.
A full list of drugs in the study found in the here.
The study also examined whether or not patients were prescribed the most common type of bone-strengthening drug, oral bisphosphonates, once the fracture had occurred. Consistent with other studies about the dismally low use of bisphosphonates after osteoporosis-related fractures, this study found that less than one-quarter of patients had filled a prescription for a bone-strengthening drug either before, or, more egregiously, after their fracture. It is important to note that the study design did not allow the capture of data on the use of IV bisphosphonates, but this probably didn’t dramatically affect the results because only 2.5% of the group were using this type of drug prior to their fracture.
Why aren’t we doing better?
There are a number of reasons why we may not be doing better when it comes to discontinuing drugs that increase the risk of fractures. It may be that the consequence of discontinuing the drug is worse than its continued use.
For example, people with intractable asthma may require glucocorticoids in order to control their symptoms. In other cases, the underlying condition itself may be the real culprit and not the drug—anti-Parkinsons disease drugs come to mind.
In other cases, it may be a matter of optimizing the dose of the drug—for example, diuretics—so that orthostatic hypotension, due to dehydration, does not contribute to falling propensity. But in other cases, such as opiates, substituting less risky drugs could be a key intervention that reduces the risk of fracture.
Similarly, there are many reasons why people with osteoporosis are not taking bisphosphonates. Doctors may not be prescribing them when they are needed or patients may be refusing them because of fear of the uncommon, but serious complications of jaw necrosis and spontaneous femur fractures that have been reported.
I believe that one of the biggest problems related to drugs, falls, and fractures is that no one “owns” osteoporosis management after a fracture. Primary care docs are pretty good about screening women (men, not so much) for low bone density. But some people with low bone density may slip into frank osteoporosis that isn’t discovered until after a fragility fracture occurs. That is what happened in my case.
Further, most people in the United States get their care in a non-integrated, non-system of healthcare. When they fall and sustain a fragility fracture, they almost always end up in an ER with a follow-up from an orthopedist. The ortho takes care of the fracture, but may or may not address the underlying bone pathology. No one thinks to ask WHY you fell or WHY you broke a big bone, like the hip or shoulder, after a fall.
Population health programs for osteoporosis
This is where population health programs for bone health come in. Not to diminish the role of the PCP, but bone health and treatment of osteoporosis is pretty complicated and the consequences of failure to diagnosis and properly treat are huge, not only because of the impact on the person’s life, but also because of the cost of care.
Because there is so much emotion around the current treatment options for osteoporosis, a specialist with a high degree of knowledge about the physiology and pathophysiology of bones and the pharmacology of the various bone-strengthening drugs can be quite valuable in helping a patient make the right choice for her (or him). I spent 45 minutes on the phone with the bone health specialist going over the recent literature before making my treatment decision. Let’s be frank here…what PCP would even have 45 minutes to spend with you to just talk about the science?
If we are going to make a dent in the tsunami of fragility fractures coming down the pike as the population ages, we are going to need to have programs that take the management of populations at risk for osteoporosis as seriously as heart failure, asthma, or diabetes. We must keep in mind that falls are not “just falls” and fragility fractures are not “just fractures.” They are painful, traumatic events that have the potential to alter a person’s life forever. We simply must do better.