Abstract
ObjectiveOsteoporotic fragility fractures, that are common in men and women, signal increased risk of future fractures and of premature mortality. Less than one-third of postmenopausal women and fewer men are prescribed active treatments to reduce fracture risk. Therefore, in this study the association of oral bisphosphonate recommendation with subsequent fracture and mortality over eight years in a fracture liaison service setting was analysed.Materials and methodsIn this prospective cohort study, 5011 men and women aged >50 years, who sustained a clinical fracture, accepted the invitation to attend the fracture liaison service of the West Glasgow health service between 1999 and 2007. These patients were fully assessed and all were recommended calcium and vitamin D. Based on pre-defined fracture risk criteria, 2534 (50.7%) patients were additionally also recommended oral bisphosphonates. Mortality and subsequent fracture risk were the pre-defined outcomes analysed using Cox proportional hazard models.ResultsThose recommended bisphosphonates were more often female (82.9 vs. 72.4%), were older (73.4 vs. 64.4 years), had lower bone mineral density T-score (-3.1 vs. -1.5) and more had sustained hip fractures (21.7 vs. 6.2%; p < 0.001). After adjustments, patients recommended bisphosphonates had lower subsequent fracture risk (Hazard Ratio (HR): 0.60; 95% confidence interval (CI): 0.49–0.73) and lower mortality risk (HR: 0.79, 95%CI: 0.64–0.97).ConclusionOf the patients, who are fully assessed after a fracture at the fracture liaison service, those with higher fracture risk and a recommendation for bisphosphonates had worse baseline characteristics. However, after adjusting for these differences, those recommended bisphosphonate treatment had a substantially lower risk for subsequent fragility fracture and lower risk for mortality. These community-based data indicate the adverse public health outcomes and mortality impacts of the current low treatment levels post fracture could be improved by bisphosphonate recommendation for both subsequent fracture and mortality.
Highlights
Osteoporotic fragility fractures are common in men as well as women
Reduced mortality and subsequent fracture risk associated with oral bisphosphonate recommendation this body of work
Of the patients, who are fully assessed after a fracture at the fracture liaison service, those with higher fracture risk and a recommendation for bisphosphonates had worse baseline characteristics
Summary
More than 50% of women and more than 25% of men aged older than 50 years will sustain a fragility fracture in their remaining lifetime.[1,2,3,4] it is clear that initial fragility fractures signal substantially increased risk of further fractures.[5, 6] Several data support the relationship between major (proximal) fragility fractures and premature mortality.[7,8,9,10,11,12,13,14,15,16,17,18,19,20,21] Secondary fracture prevention, using pharmacological treatments for osteoporosis, happens relatively rarely for women and even more rarely for men It is validated in randomised controlled trials (RCTs) and endorsed by all national guidelines.[5, 22, 23] Worldwide, there is a rising call for implementing fracture liaison services for secondary fracture prevention.[5, 22, 23] A recent review [24] reported improvement of treatment of postmenopausal US women after a fracture, but this still occurred in less than 30%. Such trials are unlikely given the major ethical challenges of randomising some participants to less than recommended care.[29]
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