Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition
Authors: Conley Robert B , Adib Gemma , Adler Robert A , Åkesson Kristina E , Alexander Ivy M , Amenta Kelly C , Blank Robert D , Brox William Timothy , Carmody Emily E , Chapman-Novakofski Karen , Clarke Bart L , Cody Kathleen M , Cooper Cyrus , Crandall Carolyn J , Dirschl Douglas R , Eagen Thomas J , Elderkin Ann L , Fujita Masaki , Greenspan Susan L , Halbout Philippe , Hochberg Marc C , Javaid Muhammad , Jeray Kyle J , Kearns Ann E , King Toby , Koinis Thomas F , Koontz Jennifer Scott , Kužma Martin , Lindsey Carleen , Lorentzon Mattias , Lyritis George P , Michaud Laura Boehnke , Miciano Armando , Morin Suzanne N , Mujahid Nadia , Napoli Nicola , Olenginski Thomas P , Puzas J Edward , Rizou Stavroula , Rosen Clifford J , Saag Kenneth , Thompson Elizabeth , Tosi Laura L , Tracer Howard , Khosla Sundeep , Kiel Douglas P 
Published: March 2020

Abstract
Osteoporosis-related fractures are undertreated, due in part to misinformation about recommended approaches to patient care and discrepancies among treatment guidelines. To help bridge this gap and improve patient outcomes, the American Society for Bone and Mineral Research assembled a multistakeholder coalition to develop clinical recommendations for the optimal prevention of secondary fractureamong people aged 65 years and older with a hip or vertebral fracture. The coalition developed 13 recommendations (7 primary and 6 secondary) strongly supported by the empirical literature. The coalition recommends increased communication with patients regarding fracture risk, mortality and morbidity outcomes, and fracture risk reduction. Risk assessment (including fall history) should occur at regular intervals with referral to physical and/or occupational therapy as appropriate. Oral, intravenous, andsubcutaneous pharmacotherapies are efficaciousandcanreduce risk of future fracture.Patientsneededucation,however, about thebenefitsandrisks of both treatment and not receiving treatment. Oral bisphosphonates alendronate and risedronate are first-line options and are generally well tolerated; otherwise, intravenous zoledronic acid and subcutaneous denosumab can be considered. Anabolic agents are expensive butmay be beneficial for selected patients at high risk.Optimal duration of pharmacotherapy is unknown but because the risk for second fractures is highest in the earlypost-fractureperiod,prompt treatment is recommended.Adequate dietary or supplemental vitaminDand calciumintake shouldbe assured. Individuals beingtreatedfor osteoporosis shouldbe reevaluated for fracture risk routinely, includingvia patienteducationabout osteoporosisandfracturesandmonitoringfor adverse treatment effects.Patients shouldbestronglyencouraged to avoid tobacco, consume alcohol inmoderation atmost, and engage in regular exercise and fall prevention strategies. Finally, referral to endocrinologists or other osteoporosis specialists may be warranted for individuals who experience repeated fracture or bone loss and those with complicating comorbidities (eg, hyperparathyroidism, chronic kidney disease).©2019American Society for Bone andMineral Research.