Practice changer
For patients with a recent hip fracture, intravenous zoledronic acid annually is an option for reducing the risk of new fractures and death.1
Strength of recommendation (SOR)
B: based on one well-designed randomized controlled trial
Lyles KW, Colon-Emeric CS, Magaziner JF, et al. Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med 2007;357: 1799–1809. Epub Sep 17.
Illustrative Case
A 75-year-old woman comes to see you 1 month after she had surgery to repair a hip fracture. She was diagnosed with osteoporosis 3 years prior to the hip fracture and is currently taking calcium and vitamin D. She tried taking an oral bisphosphonate but couldn’t tolerate the gastrointestinal side effects. What treatment can you recommend to reduce her risk of sustaining another fracture?
Background: First fracture heightens risk
Patients with a prior hip fracture have 2.5 times the risk of a new fracture compared to age-matched persons without a previous hip fracture.2 Women who have hip fractures are 3 times more likely to die in the first 6 months after the fracture than women of the same age and health status without fractures.3 Ten million people in the US have osteoporosis and 300,000 per year suffer hip fracture.4
Guidelines from the National Osteoporosis Foundation (NOF) and the Institute for Clinical Systems Improvement (ICSI) include these recommendations for hip fracture patients: discuss adequacy of total calcium and vitamin D intake; address home safety and falls prevention; and encourage specific exercises for muscle strength. They also recommend treating all patients with a prior hip or vertebral fracture with an antiresorptive agent. Options include oral bisphosphonates (alendronate, ibandronate, or risedronate), calcitonin intranasal spray or subcutaneous calcitonin, hormone therapy, parathyroid hormone, and raloxifene.5,6
Clinical context: Are we doing our best?
Most patients with hip fracture are not properly evaluated or treated for osteoporosis. A 2002 study of 500 hip fracture patients treated at 4 Midwestern health systems found that only 12% to 24% of patients had a DXA (dual-energy x-ray absorptiometry) scan either before or after hip fracture, 5% to 27% of the patients received documented advice to take adequate calcium and vitamin D, and 5% to 37% received a prescription for any antiresorptive medication (bisphosphonate [2% to 10%], estrogen, calcitonin, or raloxifene).7
Bisphosphonates are effective but compliance is poor
Bisphosphonates are effective in preventing recurrence of hip fracture. One cohort study that included over 35,000 women over age 45 who had received a bisphosphonate prescription showed that patients who are adherent to treatment have a 44.5% relative risk reduction over 2 years and an absolute risk reduction of 0.8%, for an NNT of 125.
However, compliance with oral bisphosphonate therapy is poor; only 20% of the women in this study persisted with the therapy for 24 months.8 Patients must take these medications first thing in the morning with 8 ounces of water and then remain upright for 30 to 60 minutes before eating or drinking. Gastrointestinal side effects, including dyspepsia, nausea, and reflux disease, occur in about 25% of patients, and there is a small risk of developing gastric or duodenal ulcers.
Study summary
The HORIZON Recurrent Fracture Trial was an international, randomized, double blind, placebo-controlled trial of 2127 patients with a recent hip fracture.
- The primary endpoint was a new clinical fracture.
- Secondary endpoints included the change in bone mineral density in the non-fractured hip, new vertebral and hip fractures, and pre-specified safety endpoints, including death.
Patients. Women and men age 50 or older who had undergone a surgical repair of a minimal trauma hip fracture in the previous 90 days were eligible for the study. Ninety-one percent of the patients were white, 76% were female, and the mean age was 74.5 years. Forty-one percent of patients had a T score at the femoral neck of –2.5 or less at baseline (meeting diagnostic criteria for osteoporosis).
