Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition


Robert B. Conley, Center for Medical Technology Policy
Gemma Adib, Osteoporosis Centre
Robert A. Adler, VA Medical Center
Kristina E. Åkesson, Skånes universitetssjukhus
Ivy M. Alexander, University of Connecticut
Kelly C. Amenta, Mercyhurst University
Robert D. Blank, Medical College of Wisconsin
William Timothy Brox, University of California, San Francisco
Emily E. Carmody, University of Rochester Medical Center
Karen Chapman-Novakofski, University of Illinois at Urbana-Champaign
Bart L. Clarke, Mayo Clinic
Kathleen M. Cody, American Bone Health
Cyrus Cooper, University of Southampton
Carolyn J. Crandall, University of California, Los Angeles
Douglas R. Dirschl, The University of Chicago Medicine
Thomas J. Eagen, National Council on Aging
Ann L. Elderkin, American Society for Bone and Mineral Research
Masaki Fujita, International Osteoporosis Foundation, Switzerland
Susan L. Greenspan, University of Pittsburgh
Philippe Halbout, International Osteoporosis Foundation, Switzerland
Marc C. Hochberg, University of Maryland School of Medicine
Muhammad Javaid, University of Oxford Medical Sciences Division
Kyle J. Jeray, Greenville Hospital System
Ann E. Kearns, Mayo Clinic
Toby King
Thomas F. Koinis, Duke Primary Care Oxford
Jennifer Scott Koontz, Newton Medical Center
Martin Kužma, University Hospital in Bratislava
Carleen Lindsey, Bristol Physical Therapy, LLC
Mattias Lorentzon, Australian Catholic University
George P. Lyritis, Hellenic Osteoporosis Foundation
Laura Boehnke Michaud, University of Texas MD Anderson Cancer Center
Armando Miciano, Nevada Rehabilitation Institute

Document Type

Journal Article

Publication Date



Journal of orthopaedic trauma








©2019American Society for Bone andMineral Research. Osteoporosis-related fractures are undertreated, due in part to misinformation about recommended approaches to patient care and discrepancies among treatment guidelines. To help bridge this gap and improve patient outcomes, the American Society for Bone and Mineral Research assembled a multistakeholder coalition to develop clinical recommendations for the optimal prevention of secondary fractureamong people aged 65 years and older with a hip or vertebral fracture. The coalition developed 13 recommendations (7 primary and 6 secondary) strongly supported by the empirical literature. The coalition recommends increased communication with patients regarding fracture risk, mortality and morbidity outcomes, and fracture risk reduction. Risk assessment (including fall history) should occur at regular intervals with referral to physical and/or occupational therapy as appropriate. Oral, intravenous, andsubcutaneous pharmacotherapies are efficaciousandcanreduce risk of future fracture.Patientsneededucation,however, about thebenefitsandrisks of both treatment and not receiving treatment. Oral bisphosphonates alendronate and risedronate are first-line options and are generally well tolerated; otherwise, intravenous zoledronic acid and subcutaneous denosumab can be considered. Anabolic agents are expensive butmay be beneficial for selected patients at high risk.Optimal duration of pharmacotherapy is unknown but because the risk for second fractures is highest in the earlypost-fractureperiod,prompt treatment is recommended.Adequate dietary or supplemental vitaminDand calciumintake shouldbe assured. Individuals beingtreatedfor osteoporosis shouldbe reevaluated for fracture risk routinely, includingvia patienteducationabout osteoporosisandfracturesandmonitoringfor adverse treatment effects.Patients shouldbestronglyencouraged to avoid tobacco, consume alcohol inmoderation atmost, and engage in regular exercise and fall prevention strategies. Finally, referral to endocrinologists or other osteoporosis specialists may be warranted for individuals who experience repeated fracture or bone loss and those with complicating comorbidities (eg, hyperparathyroidism, chronic kidney disease).

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