New research and recommendations were presented at ASBMR 2018, the American Society for Bone and Mineral Research Annual Meeting, from September 28 to October 1 in Montreal. The features below highlight key presentations from the conference.
Bisphosphonate Holiday & Hip Fracture Risk
American Society for Bone and Mineral Research guidelines suggest that pausing medication for a few years—a drug holiday—may be considered in select patients after 3 years of intravenous and 5 years of oral bisphosphonate therapy. However, guidance is lacking on how to proceed with therapy following the drug holiday. For a study, nearly 74,000 women aged 65 and older who had 80% adherence with bisphosphonate therapy for at least 3 years were followed for a median of 2.7 years, at which point, more than one-third had stopped taking their bisphosphonate therapy for at least 1 year. Patients who took a drug holiday from alendronate or risedronate, but not zoledronic acid, had a significantly increased risk of hip fracture compared with those who continued. Those who stopped alendronate for more than 4 years had an 80% increase in hip fractures compared with those who continued. While stopping a bisphosphonate for more than 1 year was not associated with an increased rate of vertebral or wrist/distal radius fractures, it was associated with a significantly increased risk of humerus fractures and a trend toward an increased risk of pelvic fractures.
Closing the Treatment Gap
To address the low rate of secondary therapy to treat osteoporosis in older patients who have had one of these major fractures, ASBMR issued “Secondary Fracture Prevention Initiative Clinical Care Recommendations” at the annual meeting. Clinicians treating older patients who have had a major fracture are recommended to:
- Communicate three simple messages to patients and their family/caregivers throughout the fracture care and healing process:
- Their broken bone likely means they have osteoporosis and are at high risk for breaking more bones, especially over the next 1 to 2 years.
- Breaking bones means they may, for example, have to use a walker, cane, or wheelchair, or move from their home to a residential facility, and they will be at higher risk for dying prematurely.
- Most importantly, there are actions they can take to reduce their risk.
- Make sure that the patient’s primary healthcare provider has been/or is informed that their patient has had a hip or spine fracture.
- Regularly assess the risk of falling in men and women age 65 years or older who have ever had a hip or vertebral fracture; at a minimum, ask patients about falls in the past year.
- Offer pharmacologic therapy for osteoporosis to men and women age 65 years or older who have a hip or vertebral fracture to reduce their risk of additional fractures.
- Routinely follow and re-evaluate men and women age 65 years and older who have a hip or vertebral fracture and are being treated for osteoporosis, because osteoporosis is a life-long chronic condition.
The patient care initiative also advises clinicians to:
- Consider referring the patient to a specialist if secondary causes of the hip or spine fracture need to be ruled out.
- Initiate the patient on a vitamin D supplement.
- Counsel the patient about smoking, alcohol, exercise, and calcium.
- Discuss the benefits and risks of osteoporosis treatment.
- Provide first-line therapy with oral bisphosphonates, and if the patient has difficulties with oral bisphosphonates, treat with intravenous zoledronic acid or subcutaneous denosumab. For severe osteoporosis, particularly of the spine, consider treating the patient with anabolic agents or referring them to a specialist.
- Individualize stopping and starting osteoporosis therapy for each patient.
- Consider referring patients to a specialist if they continue to have fractures or bone loss on osteoporosis treatment.
Gender & Age-Related Bone Loss
Research indicates that older women lose bone faster than men; however the spatio-temporal distribution of bone deterioration with gained in older men as it compares with that of older women is mostly unknown. Among men and women aged approximately 75 with no history of fracture participating in a study, quantitative CT scans of the left proximal femur obtained at baseline and at 5.2 years follow-up were automatically processed to assess local changes in volumetric bone mineral density (vBMD), cortical bone thickness, cortical vBMD, vBMD in a layer adjacent to the endosteal surface, and structure in men and women, as well as sex differences using several approaches. With the exception of minor spatial differences, women and men had similar spatial bone deterioration. However, women had significantly larger loses of trabecular vBMD in the femoral neck and trochanteric region, losses of cortical vBMD laterally and at the inferior-anterior cortex, losses of endosteal vBMD in the greater trochanter and inferiorly in the femoral neck, contractions of the principal compressive group and cortex, and expansions of the trabecular compartment in the greater trochanter.
DT-FPT, Falls & Physical Function in Older Adults
Evidence suggests than many falls occurring in older adults are the result of an inability to produce a rapid explosive movement when balance is lost, often while concurrently performing other attention-demanding cognitive or motor tasks. To examine whether dual task functional high velocity (power) training (DT-FPT) can help reduce falls and improve physical function in older adults, study investigators randomized residents at risk of falling from 22 independent living retirement villages to DT-FPT involving high velocity strength and mobility training performed simultaneously with cognitive or motor tasks, or a usual care control (CON) group. The intervention consisted of 6 months supervised training (45-60 min, 2/week) at each village followed by a 6 month maintenance program. Among 89 falls by 65 participants during the first 6 months, the rate of falls was 30% lower in the DT-FPT group, although the difference was not significant. However, the relative risk for two or more falls was significantly lower in the DT-FPT group. Compared with the CON group, DT-FPT patients significantly improved muscle power, mobility, and choice stepping reaction time, as well as experienced greater improvements in dual task motor and cognitive gait speed.