Avoid widespread use of bisphosphonates in patients at low risk.
HFHT's Practising Wisely Newsletter
For clinicians, by clinicians.
Issue 18: Sometimes, Falls Prevention is the Best Kind of Fracture Prevention
March 28, 2017
Last week we talked about bone density testing. This week we're continuing the conversation by talking about treating osteoporosis or preventing fractures.
Based on your patient's risk assessment and/or age, a bone density test is carried out. What to do with the results? What is the patient's risk of fracture?
Avoid widespread use of bisphosponates in patients at low risk
The Canadian Rheumatology Association states that, in treating osteopenia, or “pre-osteoporosis”,
health care providers should avoid prescribing bisphosphonates for patients at low risk of fracture.
There is no convincing evidence that anti-osteoporotic therapy in patients with osteopenia alone reduces fracture risk. The 2008 Cochrane Reviews for three bisphosphonates (Alendronate, Etidronate, Risedronate) found no statistically significant reductions for primary prevention of fracture in postmenopausal women. Fracture risk is determined using either the Canadian Association of Radiologists and Osteoporosis Canada risk assessment tool (CAROC) or FRAX®, a World Health Organization fracture risk assessment tool. Both are available as online calculators of fracture risk. Given the lack of proven efficacy, widespread use of bisphosphonates in patients at low risk of fracture is not currently recommended. Check out our Quick Links section to find the recommendations by the Canadian Rheumatology Association and to view the fracture risk tools mentioned above.
For more detailed discussion of this topic, please visit our Quick LInks for an article by Alonso-Coello, Garcia-Franco, Guyatt and Moynihan (2008) published in the British Medical Journal.
Prevent fractures in older people by preventing falls
The spectrum of pharmacotherapy to boost bone density is the subject of a future briefing, but also consider that preventing fractures in older people is important.
Teppo Järvinen and colleagues believe that we should be putting our efforts into stopping falls, not treating low bone mineral density. Read their BMJ article in full by visiting our Quick Links section, or check out the key points below:
Falling, not osteoporosis, is the strongest single risk factor for fractures in elderly people.
Bone mineral density is a poor predictor of an individual’s fracture risk.
Drug treatment is expensive and will not prevent most fractures in elderly people.
Randomised controlled trials show that falls in older people can be reduced by up to 50%.
General practitioners should shift the focus in fracture prevention by systematically assessing risk of falling and providing appropriate interventions to reduce the risk.
So, in summary, take a pass on the prescription pad for those in the low risk category, and instead support strategies such as smoking cessation, and strength and balance training. There are fewer side effects, and no renewals necessary!