Fragility fractures are a common — but not inevitable — part of aging. These bone fractures, which occur during normal activities or following a fall, are a leading cause of pain, disability and loss of independence among older adults. Approximately half of all women and a quarter of all men age 50 and older will suffer from one or more fragility fractures in their remaining lifetime.
Factors that can increase a person’s fracture risk include older age, family history and — perhaps less widely known but crucially important — the side effects of certain medications. Certain medications can make some patients more susceptible to falls, while others lead to decreased bone density, making bones more prone to break. A group of researchers recently measured how often fragility fracture patients were using medications that have been linked to increased fracture risk, both before and after their fracture events. What they found may surprise you.
Unchecked risk factor
Using a sample of Medicare insurance claims, the researchers identified nearly 170,000 patients who had experienced fragility fractures of the hip, shoulder or wrist between 2007 and 2011. They examined records of prescription drug fills to determine whether patients had used certain medications during the 120 days before and after their fracture events. The researchers focused on commonly used drugs known to be associated with side effects that increase fracture risk: sedatives, antipsychotics and antidepressants (in this study, termed “fracture-promoting drugs”). They expected to see that patients previously using fracture-promoting drugs would discontinue use after experiencing a fragility fracture in order to lower their risk of future fracture events. In reality, this rarely happened.
More than 75 percent of fragility fracture patients had been using fracture-promoting drugs during the four months prior to their fractures. But remarkably, very few patients discontinued use of these drugs following their fracture events — and a small number actually initiated new use of fracture-promoting drugs following their first fracture. As a result, the overall percentage of patients using fracture-promoting drugs actually increased somewhat, despite known risks. In comparison, only 1 in 5 patients used osteoporosis drugs that may reduce fracture risk — either at the time of the fragility fracture, or during the subsequent four months.
A first fracture event should serve as a wake-up call to assess the array of modifiable risk factors that determine likelihood of subsequent fractures. But that wake-up call is not always heard. In fact, Pam Morin and I recently reported on the startling finding that women are rarely evaluated or treated for osteoporosis following hip fractures. And there are other missed opportunities to intervene, as highlighted by the present study.
Following fragility fracture events, patients should engage in appropriate rehabilitation and physical activity to improve balance and strength, have their vision checked, and examine their surroundings to identify simple home modifications that may reduce risk of falling. But that’s not all they should do.
Patients, especially those with a history of fragility fracture, should review all medications they use with their health care provider — and should discuss the potential benefits and risks associated with reducing, substituting or eliminating use of medications with side effects known to increase risk of falls or lessen bone density. Patients and family caregivers may not even realize that some of the medications they are using can increase the risk of fragility fracture.
Every treatment decision has an associated trade-off. Health care providers play an essential role in reducing potentially harmful prescribing practices, and patients should know they have a right to choose.
Munson JC, Bynum JPW, Bell J-E, Cantu R, McDonough C, Wang Q, et al. Patterns of Prescription Drug Use Before and After Fragility Fracture. JAMA Intern Med. 2016 Oct 1;176(10):1531–8.
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