Expert panel evaluates role of osteoporosis medications in fracture healing

In people with osteoporosis, one fracture often leads to more fractures, and potentially a future of pain, disability, and poor quality of life. While studies have shown that such high-risk patients benefit from appropriate medication to reduce future fracture risk, more research is needed on the effect of osteoporosis medications on fracture healing.

With the goals of improving patient care and promoting future clinical studies, the International Osteoporosis Foundation (IOF) Fracture Working Group convened to review existing literature and vote on appropriateness of care for fracture healing.

The multidisciplinary panel of experts used a validated consensus method (RAND USCLA appropriateness methodology - RUAM) to find agreement on statements and scenarios for these main issues: effect of osteoporosis medications on fracture healing; risk factors for delayed fracture healing; clinical and research goals; guidelines for future trial design; and clinical scenarios of fracture healing.

Lead author Professor Stuart Silverman, Cedars-Sinai Medical Center and Clinical Professor of Medicine, University of California, Los Angeles (UCLA) stated, "There has been little data on the role of osteoporosis medications in fracture healing and as a result there is little consensus or clinical guidance on how soon after fracture medications should be prescribed. We hope that this consensus report will help to set the scene for both improved patient care and good clinical study design for future research in this area."

In regard to the effect of osteoporosis medications on fracture healing, the key panel agreements included the following:

• Delayed fracture healing is common. Preventing delayed fracture healing should be a goal of providers treating patients with fractures. It is valuable to identify those patients at increased risk of delayed fracture healing as early as possible in order to consider intervention.
• Antiresorptives such as bisphosphonates may delay fracture healing; however the risk is low. There was no evidence for delay in fracture healing when injectable bisphosphonates were given in the first two weeks after fracture.
• Anabolic agents such as teriparatide which enhance osteoblastic bone formation may have a beneficial effect on fracture healing.
• The panel suggested guidelines for future trial design to understand the role of osteoporosis medications on fracture healing.
• In conclusion the experts agreed that there was no negative effect of osteoporosis medications on fracture healing, and that it is safe to start osteoporosis medications as soon as possible after both vertebral and nonvertebral fracture. However, the panel agreed that after the occurrence of an atypical femur fracture, bisphosphonate therapy should be stopped. Treatment with an anabolic agent such as teriparatide should be considered to improve healing.

Professor Cyrus Cooper, Chair of the IOF Committee of Scientific Advisors (CSA) commented, "If appropriately treated, patients who have suffered a first fracture can considerably reduce their risk of future debilitating fractures. This consensus report provides clinicians with an excellent point of reference on the effects of osteoporosis medications on fracture healing, including when making treatment decisions in regard to patients who are experiencing delayed fracture healing. It is also a valuable blueprint for future clinical studies on the role of osteoporosis medication and fracture healing."

The paper 'Fracture healing: A consensus report from the International Osteoporosis Foundation Fracture Working Group' has been published in the journal Osteoporosis International.