Pharmacologic Tx To Prevent Fractures: A Review

the MPR take:

A review published in the Annals of Internal Medicine provides an update on the benefits and harms associated with drug treatment for fracture prevention in adults at risk. Researchers searched multiple databases for studies conducted between January 2005 and March 2014; 315 articles were included for this review. Based on this data the authors were able to come to the following conclusions about drug effectiveness and side effects:

  • To prevent vertebral fractures in women with osteoporosis, strong evidence exists for alendronate, ibandronate, risedronate, zoledronic acid, denosumab, teriparatide, and raloxifene.
  • To prevent nonvertebral fracture in women with osteoporosis, strong evidence exists for alendronate, risedronate, zoledronic acid, denosumab, and teriparatide.
  • To prevent vertebral fractures in men with osteoporosis, moderate evidence exists for zoledronic acid.
  • Strong evidence points to mild upper GI symptoms with bisphosphonates, denosumab, and teriparatide; hot flashes and thromboembolic events with raloxifene; headache and hypercalcemia with teriparatide; and hypocalcemia and influenza-like symptoms with zoledronic acid. 
  • Moderate evidence exists for infection associated with denosumab use. 
  • Subtrochanteric fracture and osteonecrosis of the jaw are very rare side effects of bisphosphonates. 

As for head-to-head studies, data on comparative effectiveness is lacking; the authors note that the differences among bisphosphonates, teriparatide, and denosumab are likely modest. For alendronate, the evidence suggests that for some patients the drug can be discontinued after 5 years; no good evidence exists to recommend optimal treatment duration for other agents at this time.

Osteoporosis is a major contributor to the propensity to fracture among older adults, and various pharmaceuticals are available to treat it.