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Fighting future fractures

Just as lightning can strike the same target more than once in a given storm, hip fractures can and do happen again to the same person. Yet, more often than not, people who fracture a hip do not get follow-up treatment that could prevent another fracture.

Studies have shown that after a hip fracture is repaired, patients often fall through the cracks, leaving them at risk of a recurrence. The surgeon’s job ends with fixing or, more likely, replacing the broken hip. It’s then up to the patient’s personal physician to recommend and prescribe measures to help prevent a second fracture.

However, the typical 15-minute office visit is often focused on current medical issues, like diabetes and high blood pressure, rather than on a possible future problem, albeit one that can be life-threatening. In many cases, experts say, practicing physicians don’t even know which of their patients have had a hip fracture.

Anyone who breaks a hip, unless from a severe trauma like a car accident, is considered at high risk for further fractures, including breaking the other hip. To reduce the risk, orthopedic experts recommend that after a fracture, patients should have a bone density test, evaluation of calcium and vitamin D levels and, in nearly all cases, medication to protect against further bone loss.

Even without a bone density test, Dr. Douglas C. Bauer, internist at the University of California, San Francisco, wrote in an editorial in JAMA Geriatrics in July, “There is almost universal agreement that individuals with documented hip or vertebral fracture have established osteoporosis, indicating that they are at high risk of future fracture, and appropriate drug therapy should be routinely offered.”

In an interview he said, “Every patient with a reasonable life expectancy who has a hip fracture should be offered treatment.”

Bauer was reacting to what he called “really depressing, shocking data” revealing that only a small — and steadily declining — fraction of hip-fracture patients are being treated with medication that might forestall future broken bones.

“Things aren’t getting better, they’re getting worse, despite the fact that there are quite a large number of treatments that have been proven effective and are now inexpensive,” he said.

The distressing evidence comes from a national study of 97,169 patients who fractured a hip from 2004 through 2015. Published in JAMA Geriatrics, the study, by Dr. Rishi J. Desai, epidemiologist at Brigham and Women’s Hospital, and co-authors showed a continuous decline in patients who started taking osteoporotic medications after the fracture, from 9.8% of patients in 2004 to a dismal 3.3% in 2015.

The decline in initiating treatment with any of the many medications known to reduce fracture risk is widely attributed to the outsize publicity given to the very rare risk of jaw necrosis and an uncommon fracture of the femur among patients who take bone drugs for many years. Yet the risk of a second hip fracture is far greater than either of these side effects, Bauer said. (The Food and Drug Administration just approved a new and different drug, Evenity, which builds bone, but it may have its own risks, this time a small increase in the chances of having a heart attack or stroke. Also, it is very expensive and may not be covered by insurance, and licensed only for postmenopausal women with a high risk of fracture.)

In Desai’s study, treatment rates among those who broke a hip were even lower for men than for women, although men are nearly as likely to break another bone, including the other hip. In general, without preventive treatment, 15% to 25% of patients who suffer an osteoporotic fracture will experience another one within 10 years.

And with people living longer, hip fractures are increasingly likely. A report published last year in the journal Osteoporosis International revealed that, after a decade of declining rates of hip fractures, since 2012 the rates have plateaued in the United States — most likely because so many older adults and their doctors have turned their backs on bone-protecting medication. Among people enrolled in Medicare alone, Desai and co-authors wrote, this plateau “may have resulted in more than 11,000 additional estimated hip fractures between 2012 and 2015.”

The side effects associated with bone drugs “have gotten more hype than they should have,” Desai said in an interview. “People worry about them, and with preventive therapy, they don’t see the benefits right away.”

However, Bauer wrote, “hip fractures represent only the tip of the iceberg; timely evaluation and consideration of drug treatment are appropriate for many other individuals at high risk of fracture.”

Many people at risk of breaking a bone because of osteoporosis are reluctant even to take vitamin D and calcium, nutrients critical to forming healthy bones. In a new national study reported recently by Dr. Spencer Summers, orthopedic surgeon at the University of Miami, to the American Academy of Orthopaedic Surgeons, fewer than 1 person in 5 known to have osteoporosis met the daily recommended intake of both vitamin D and calcium.

More than 10 million Americans have osteoporosis, and another 44 million are at increased risk of developing it. Osteoporosis, which means porous bones, is a chronic, progressive disease of increasingly fragile bones that can break from a relatively minor insult, like falling from a standing height.

Sooner or later, osteoporosis results in half of white women and 20% of white men breaking a bone (the risk is significantly lower in African-American and Hispanic adults); when that bone is a hip, the outcome too often is a tragic decline in quality of life, permanent disability or even death. Among elderly patients who break a hip, the mortality rate within a year is as high as 36%.

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