While this effect may not be a problem for bisphosphonates dosed more frequently, it would seem important to wait at least two weeks after the fracture if yearly zoledronic acid therapy is planned. Unfortunately, current reimbursement discourages treatment for intravenous bisposphonates in rehabilitation or skilled nursing facilities, who must provide the drug out of a capitated payment. Coordination of the infusion with postoperative follow-up appointments may be possible. Initiating oral bisphosphonate is a simpler alternative therapy for those patients in whom infusions are not available or practical, although the direct evidence of their benefit is weaker. It is not necessary to wait for BMD measurement prior to initiating therapy, as treatment is indicated and effective regardless of baseline BMD.
It appears that the antifracture efficacy of bisphosphonates is substantial in hip-fracture patients despite their competing comorbidities and lower life expectancies.
Although HORIZON-RFT included an older population than is typical for osteoporosis trials, it is likely that the enrolled patients represented the healthiest subset of the hip-fracture population. Is there a group of patients who are “too frail” for treatment, in whom the risks and costs outweigh the benefits? Using a large Medicare sample, Curtis and colleagues demonstrated that, although the five-year risk of death after osteoporotic fracture in older adults usually exceeds the risk for second fracture across patient-demographic and fracture-type groups, the five-year risk for second fracture is also high, varying from a low of 13% to a high of 43%. Furthermore, the number of fracture patients who needed to be treated to prevent a second fracture was low, ranging from eight to 46 across all demographic groups.19
Although not specific to hip-fracture patients, a recent model examined the cost-effectiveness of five years of oral alendronate treatment in women with osteoporosis whose ages ranged from 50 to 90 years, and whose life expectancies varied from the highest to the lowest quartiles. Even in women at the oldest ages in the lowest quartile of life expectancy, which is likely representative of many hip-fracture patients, treatment was highly cost effective.20 While such analyses specific to the more expensive agents such as zoledronic acid are lacking in hip-fracture patients, given the efficacy of this agent in both fracture reduction and mortality, the results are likely to be similar. Therefore, our practice is to consider treatment in hip-fracture patients whom we judge to have a life expectancy of at least six months if such treatment is consistent with the patient’s goals of care.
Conclusion
Patients with hip fracture are an important and, until recently, overlooked population in which to consider bisphosphonate treatment. Solid data from clinical trials now show that such treatment is safe and effective in reducing both subsequent fractures and mortality, and it is likely to be cost effective in even the frailest patients. Since practical barriers to treatment can be significant it is important for hospital or provider groups to establish systems to ensure that eligible patients are offered treatment (see Figure 2).
Disclosures
Dr. Colón-Emeric is a consultant for Novartis, Amgen, and Daiichi Sankyo; receives research support from Novartis, Pfizer; and has a patent for the cardiovascular effects of bisphosphonates.
