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Clinical Pathways

Orthopaedics
Fragility Fractures

Background

Clinically, a fragility fracture may be defined as a fracture that occurs as a result of minimal trauma, such as a fall from a standing height or less, or no identifiable trauma in any patient 50 years of age or older.

Assessment

  1. Refer for DEXA

    • A limited number of DHB-funded DEXA bone mineral density (BMD) scans are available for primary care clinicians.  Follow up and management is the responsibility of the clinician who orders the scan.
    • Patient eligibility - ALL SEVEN of the following criteria must be met:
      1. The patient is between the ages of 50 and 75 (those aged over 75 who have a fragility fracture meet the criteria for bisphosphonate therapy without DEXA scanning)
      2. The patient has a recent (within last 4 months) fragility fracture, i.e. a fracture of wrist, humerus, ankle, pelvis, vertebrae or ribs that has been caused by a minimal trauma event usually as a result of a fall from a standing height or less.
      3. The patient has not had a DEXA scan in the last 18 months
      4. The patient has not had an isolated fracture of the face, hands, feet or clavicle
      5. The patient does not have a fracture caused by evident trauma, e.g. motor vehicle accident or fall from ladder
      6. The patient is not already on antiresorptive osteoporosis medication
      7. The patient has not been reviewed by the Fracture Liaison Service in BOP (i.e. used hospital services for fracture treatment) AND has not had a hip fracture.
    • Not all patients will require a DEXA scan but all should be considered for one.
    • Recent DEXA scan: If the patient has had a DEXA scan in the past 18 months to 2 years, please seek expert advice as the margin of error for the measurement often exceeds any actual differences in bone mineral density within this time frame and may not provide useful information.
    • DEXA scanning procedure: this takes approximately 15 minutes, is not claustrophobic and carries little risk. Other than pregnancy, there are few contraindications. However, the patient must be able to lie flat and flex their hips slightly so please do not refer your patient for a bone scan if they are unable to do this or if they would be within 2 weeks of a hip fracture (contraindicated).
    • Primary prevention: Patients without fragility fracture will not at present be eligible for DHB- funded DEXA scanning but which can still, of course, have this done privately.
    • How to refer: An eReferral is available via BPAC. Type ‘dexa’ into the search field for the WBOPPHO eReferral form.

Management

  1. Lifestyle

  2. Physical Therapy

    • Activity, exercise classes and physical therapy can reduce the risks of falls by improving strength, flexibility, balance, and other parameters. In established osteoporosis, physical activity will not significantly improve bone strength unless performed to a high level, often in combination with strength resistance work. In these situations, assessment of increased fracture risk is mandatory.
    • Exercise programmes and exercise groups can result in significant improvement in physical function, pain, and vitality domains.
    • Age Concern Tauranga has a list of fitness classes in the Tauranga region.
    • Sport BOP Strength & Balance classes across the Bay of Plenty region.
    • Physiotherapy:  Private physiotherapy will often be ACC subsidised in this patient group and should be your first option. Some private physiotherapists also do home visits.
    • DHB funded Community physiotherapy can be requested but in order to ensure demand does not exceed capacity, the private option should be your first option if possible.
    • A referral to the Community Geriatrics Service (CGS) may be appropriate to assist with the activities of daily living – please see BPAC eReferral.
    • Love your Bones Exercise exercise fact sheet

  3. Bisphosphonate Treatment

    • Treatment is only indicated for patients with a Bone Mineral Density showing osteoporosis (T score of worse than -2.5). Although osteopenia (T score -1 to -2.5) is a risk factor for future fracture, there are currently no trials showing benefit of treatment in these patients as a group.
    • The following general recommendations for the treatment of osteoporosis including secondary prevention of fragility fracture are currently considered 'best practice'.  This is not a comprehensive clinical treatment guideline. Seek advice if unsure via Nicola Ward, Fracture Prevention Service, BOPDHB, 07 557 5570 or 027 8013 723.
    • For all situations listed below, ensure adequate calcium and vitamin D intake.
      • Bisphosphonate is recommended unless contraindicated (or considered inappropriate for other reasons e.g. limited life expectancy).
      • Choose any one of Risedronate (no special authority required), Alendronate, Zoledronic acid
      • (see below for differentiating factors). Etidronate is no longer recommended.
      • NB: Pharmaceutical manufacturers of bisphosphonates do not recommend bisphosphonates if calculated creatinine clearance (Cockroft and Gault)<30ml/min (risedronate) or <35ml/min (alendronate, zoledronic acid).
      • If a patient experiences a further fracture on anti-osteoporosis treatment, it is not necessarily an indication that the treatment should be changed or discontinued. Check adherence and exclude secondary causes of osteoporosis. Decision to continue or change treatment may be influenced by a number of factors including length of time patient has been on treatment and degree of worsening of BMD measurements. Consult if unsure, via HIA e-Referral or contact Fracture Prevention service as above. 
    • How to choose between bisphosphonates?
      • The following three bisphosphonates have similar licensed indications. The evidence base differs for each one, but a class effect is generally assumed.
        1. Good evidence to support secondary prevention for hip, vertebral and non-vertebral fractures.
        2. Low quality evidence to support secondary prevention for wrist fractures
        3. May have fewer upper GI adverse effects than alendronate (patients with GI disorders were included in clinical trials).
        4. No special authority required.
      • See also:
        1. Good evidence to support secondaryprevention for hip, vertebral and non-vertebral fractures.
        2. Low -quality evidence to support secondary prevention for wrist fractures.
        3. Good evidence to support primaryprevention for vertebral fractures only.
          May have more upper GI adverse effects than risedronate (patients with GI disorders were excluded from clinical trials).
        4. Needs Pharmac special authority number.*
      • *Find the 'Alendronate Tab 70 mg - with or without Cholecalciferol' Special Authority Form under the 'Musculoskeletal System' heading on the Pharmac 'Special Authority Forms' webpage.
      • See also:
      1. IV; may be useful if problems with adherence, absorption, ability to comply with oral administration requirements, (e.g. in dementia, cognitive impairment, memory loss), severe GI problems e.g. acute oesophageal/gastric inflammation or ulceration, oesophageal strictures, achalasia, scleroderma.
      2. GP practices charge a fee to administer IV, cost may be a barrier for some patients.
      3. Zoledronate is an IV bisphosphonate that reduces risk of hip, vertebral and non-vertebral fractures.5 In the pivotal clinical trials, Zoledronate was administered annually for three years. However, Zoledronate’s duration of action is considerably longer than one year; therefore, it is common practice to administer the three initial doses at intervals of 18 or 24 months.
      4. Contraindicated if calculated creatinine clearance (Cockroft and Gault)<35ml/min. Can cause deterioration in renal function in patients with pre-existing renal impairment. See IV administration protocol for more information. Contraindications to Zoledronate include: creatinine clearance or eGFR <35 mL/min; marked vitamin D deficiency; and
      5. The most common side effect of Zoledronate is post-dose flu-like symptoms (affecting approximately 30% of patients), the majority of which occur within the first 3 days following Zoledronate administration and resolve within 3 days. The incidence of these symptoms can be reduced with administration of paracetamol shortly after the Zoledronate dose. These symptoms decrease markedly with subsequent doses of Zoledronate (incidence of 1–2%). Ensure adequate hydration.
      6. Needs Pharmac special authority number.**

      • Treatment review is essential as there may be an increased incidence of rare adverse effects with long-term bisphosphonate use. Review risedronate and alendronate after 5 years and zoledronic acid after 3 years.
        • Clinical trials have shown that after 3 to 5 years of bisphosphonate therapy, patients whose femoral T-score has risen above -2.5 and who have not had new fractures are able to discontinue bisphosphonate treatment for up to 5 years without an increase in their future fracture risk. Therefore, remaining off treatment for 4 to 5 years is appropriate for patients meeting these criteria.
        • Seek advice if unsure via Nicola Ward, Fracture Prevention Service, BOPDHB, 07 557 5570 or 027 8013 723.
        • Continue if high risk but re-review annually; high risk factors:
          • Prior hip or multiple vertebral fractures
          • Age ≥ 75 years
          • Continued fragility fractures on treatment
          • Total hip or femoral neck BMD T-score ≤ -2.5 at time of treatment review
          • Recurrent falls
          • Other risk factors including secondary osteoporosis, co-morbidities, oral glucocorticoids
      • After a total of 10 years for risedronate and alendronate or 6 years for zoledronic acid, stop bisphosphonate but continue adjunctive therapies i.e. vitamin D, dietary advice, falls prevention.
      • When treatment is discontinued, fracture risk should be reassessed every two years or after a new fracture (regardless of when this occurs).
    • Second Line Therapy

      • Teriparatide is a fragment of parathyroid hormone, administered by once-daily subcutaneous injection, that may be used in patients with established osteoporosis and recurrent fracture and following at least 12 months of antiresorptive therapy.

      • Denosumab is a monoclonal antibody directed against RANK-ligand, administered by subcutaneous injection every 6 months, for treatment of osteoporosis. Denosumab is not yet reimbursed in New Zealand.

    • Other treatments

      • SERMS (e.g. raloxifene) could be considered as an alternative to oestrogen therapy in postmenopausal women, although raloxifene does not prevent hip or other non-vertebral fractures.

      • Strontium ranelate is not recommended because of its adverse cardiovascular profile.

      • If considering treatment with Teriparatide please ensure patient meets Pharmac special authority criteria*** for eligibility, and if the patient is eligible refer to the Fracture Prevention Service via Health in Ageing eReferral (Annotate referral with Fracture Prevention Service).
      • ***Find the 'Teriparatide' Special Authority Form under the 'Musculoskeletal System' heading on the Pharmac 'Special Authority Forms' webpage.
      • Raloxifene
      • HRT

  4. Reduce Adverse Medication

    • Many medications are known or suspected to reduce bone density although the impact of this on clinical fracture rates varies and is the subject of ongoing scientific debate. The association is stronger and better quantified for some of the following classes (aromatase inhibitors, glucocorticoids, GnRH agonists) than others. 
      Medicine class Medications Suggested approach

      Anticonvulsants

      Phenytoin, carbamazepine, primidone, phenobarbitone, sodium valproate

      Consider changing to newer anticonvulsants or give vitamin D (1 x 1.25mg (50,000 IU) tablet fortnightly rather than monthly)

      Aromatase inhibitors

      Anastrozole, letrozole, exemestane

      Supplement calcium and vitamin D if dietary intake inadequate; for high-risk patients consider co-prescribing anti-resorptive medicine e.g. bisphosphonate

      Depot medroxyprogesterone Acetate (DMPA)

      Depo Provera

      Impact depends on age and duration. Ensure adequate calcium and vitamin D intake, encourage weight-bearing exercise

      Glucocorticoids

      Prednisone

      Ensure lowest effective dose and duration, consider co-prescribing anti-resorptive medicine e.g. bisphosphonate

      GnRH agonists

      Leuprorelin (Lucrin®), goserelin (Zoladex®)

      As for aromatase inhibitors

      Long term heparin use

      -

      Dose and duration related (>15,000 units unfractionated heparin per day for >3 months). Risk may be lower with LMWH than UFH

      Pioglitazone

      -

      Contraindicated in osteoporosis – do not use

      PPIs

      Lansoprazole, omeprazole, pantoprazole

      Keep dose and duration as low as possible (increased risk of fracture after 5 years); consider change to ranitidine or famotidine

      SSRI and SNRI antidepressants

      Citalopram, fluoxetine, paroxetine, sertraline, venlafaxine, mirtazapine

      Regularly review ongoing need for antidepressant

      Thyroxine

      -

      Ensure TSH within normal range and not ‘over-replaced’
    • This medication review and rationalisation should be a routine part of osteoporosis management as should the reduction of medication likely to aggravate risk of falls (see Bay Navigator pathway for Falls Prevention - to be available later). Seek advice if unsure via Fragility Fracture pathway group member Pauline McQuoid, phone 021 864 996 or by utilising the 'advice only' tab of the HIA eReferral form.

  5. Calcium and Vitamin D

    • Calcium and vitamin D advice differs depending on the target population. The following recommendations apply to patients with osteoporotic fracture.
      • There has been a progressive decrease up until recently in recommended calcium intake over recent years, especially in the context of people having additional Vitamin D. A dietary calcium intake of 1,000 to 1,300mg/day elemental calcium has been recommended although a target of 500mg - 1,000mg is adequate for most. Dairy products not only provide calcium but also many other beneficial components such as protein, fluid, phosphate, leucine for muscle replenishment and factors for bone growth. Calcium-enhanced milk ("yellow-top") contains approximately 500mg of calcium per 250ml. Dietary intake is far preferable to supplementation but if this is not possible, consider supplementation with 500mg once a day preferably with the evening meal (500mg elemental calcium = 1250mg calcium carbonate).
      • Calcium calculator
      • Calcium NZ formulary
      • International Osteoporosis Foundation
      • The recommended vitamin D intake for patients with established osteoporosis is at least 1000 IU per day. Most people will need supplementation to achieve this. There is no need to measure Vitamin D levels.
        • Dose recommendations vary; prescribe a loading dose of colecalciferol (VitD3 1.25mg = 50,000IU).  Prescribe ONE capsule followed by another tablet two to three days later. This is then followed by a maintenance dose of ONE capsule ONCE a month only.
        • Obese patients may need higher doses.
        • Patients with hypercalcaemia should be referred for specialist advice. Some of these patients can have vitamin D with monitoring but without a calcium enhanced diet.
      • Vitamin D for Zoledronic acid (Aclasta) infusion:
        • Vitamin D stores must be adequate before administering IV zoledronic acid (Aclasta®) and serum calcium must be in the normal range. There is no need to measure Vitamin D levels. If not already receiving vitamin D (colecalciferol), give one tablet of 1.25mg  (total 50,000IU) colecalciferol (VitD3) in the week prior to infusion.  Continue vitamin D supplementation by prescribing one tablet of 1.25mg (50,000IU) colecalciferol once a month as maintenance therapy.

  6. Follow Up and Further Investigation

    • Follow-up of your patient may be to discuss results, to choose the medication programme for your individual patient, to encourage compliance, to provide lifestyle advice or to manage recurrent fallers..
    • Follow-up may also be required if your patient experiences further fracture. In this case please note:
      • Although the treatment regimen (usually with bisphosphonate) is highly effective it by no means removes completely the risk of further fracture. If your patient experiences a further fracture on anti-osteoporosis treatment, it is not necessarily an indication that the treatment should be changed or discontinued. Seek advice from the Fracture Prevention Service if unsure via an eReferral to Health in Aging and annotate referral with Fracture Prevention Service.
      • Repeat DEXA scanning is of no additional value if repeated too early. At least two and possibly three years should elapse before further evaluation.
      • Detailed investigation and review may be carried out either:
      • By yourself as the primary care physician, in which case the information below will provide useful information on a suitable bone health history and Investigations.

    or

      • By referral to the Fracture Prevention Service via an eReferral to Health in Ageing annotate referral with Fracture Prevention Service. This may be indicated because of factors such as:
        • Repeated fracture despite apparently adequate and appropriate therapy
        • Malnutrition
        • Frailty syndrome and/or dementia
        • Other related co-morbidity e.g. respiratory failure, steroids, high alcohol intake, male gonadotrophic block
        • Frequent falls
    • Before referral, ensure that any causes of secondary osteoporosis are identified and managed optimally. Patients with severe and recurrent falls may be referred to the Health in Ageing Service.
    • Referral to the Fracture Prevention Service should include your patient's relevant bone health history and current medication list, and can be made by eReferral or in writing.
      • In addition to an estimate of bone mineral density, a number of other investigations may be useful. They should not be used routinely as they are expensive and may lead to unnecessary distress to your patients. A DEXA scan is not a mandatory prerequisite to starting your patient on anti-resorptive medication, especially for routine age-related osteoporosis in patients ≥ 75 years old.
      • The following investigations maybe useful in most cases of suspected osteoporotic fracture:
        • FBC
        • U&Es and creatinine
        • Calcium (corrected for albumin level) and phosphate and magnesium
        • Alkaline phosphatase
        • ESR
        • TSH
      • The following investigations may be useful to detect underlying pathology other than osteoporosis:
        • Vitamin D (specialist only)
        • Parathyroid hormone
        • LFTs (Primary Biliary Cirrhosis)
        • AMA & ANA antibody screen
        • CRP
        • PSA (Prostate Cancer)
        • Protein electrophoresis (Myeloma)
        • X-ray skeletal survey (Metastatic bone disease)
        • Various tumour markers / x-rays (underlying cancer)
        • Testosterone (male hypogonadism) Free androgen index?
        • LH/FSH (Ovarian failure)
        • HbA1c
      • The following investigations (specialist use only) may be useful in particularly complex cases to identify the current state of bone metabolism:
        • Beta - CTX (bone resorption)
        • P1NP (bone formation)
          • Current Osteoporosis management and treatment guidelines indicate taking a P1NP blood test at 6 months post starting oral bisphosphonate.
          • P1NP is an expensive blood test costing $ 47.41.
          • Oral bisphosphonate absorption is poor, and adherence to treatment has been known to be variable. P1NP may be useful to confirm a) effective absorption B) patient adherence to treatment.
          • Effective bisphosphonate treatment should reduce P1NP levels to <35mcg/L.
      • If you have concerns about the effectiveness of oral bisphosphonate treatment, consider IV Zoledronic Acid or consult with HIA Fracture Prevention Service for an opinion on the role of P1NP testing. 
      • Repeat bone mineral density (BMD) scanning should generally not be repeated within 2 to 3 years from the last. Thereafter, repeat DEXA scanning may assist in trying to decide whether to stop, continue or change anti-osteoporosis medication after 3-5yrs of treatment.

Information

Disclaimer: These pathways, for the care and management of patients within Bay of Plenty, have been developed jointly by primary and secondary care clinicians. They provide guidance for General Practice teams to diagnose and manage patients suffering from a number of different conditions, and contain patient information resources. The pathways are maps of publicly-funded services accessed by referral from the community, and are strongly evidence based, but are not full clinical guidelines. As the pathways are suggested guidance only, while using them you must exercise your own clinical judgement and pertinent clinical data when treating your patient. This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.