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Three Part Question

In [an elderly patient with a hip fracture] when [should bisphosphonates be started to decrease the risk of subsequent fractures] without [disrupting bone remodeling or causing delay of fracture union]

Clinical Scenario

An 85 year old female patient presented to emergency department with a hip fracture. She has been on bisphosphonates for the past few months. You know that with recent fractures bisphosphonates should be stopped so as not to disturb bone healing but you wonder how soon the patient should restart them.

Search Strategy

Ovid MEDLINE(R) 1946 to June Week 1 2012

[hip fractures/et or Hip Fractures/su] AND [Diphosphonates/tu (Therapeutic Use)] AND [Osteoporosis/ or osteoporosis.mp.] AND [Time Factors/]. Limit to human and English language.

Search Outcome

7 papers were found, only one clinical study addressed the timing of bisphosphonate therapy after hip fracture.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Eriksen et al 2009 Switzerland	A total of 2127 patients (1065 on active treatment and 1062 on placebo; mean age, 75 yr; 76% women and 24% men) were administered zoledronic acid or placebo within 90 days after surgical repair of an osteoporotic hip fracture and annually thereafter, with a median follow-up time of 1.9 years.	A post hoc analysis of data from the Health Outcomes and Reduced Incidence With Zoledronic Acid Once Yearly Recurrent Fracture Trial (HORIZON-RFT)which was a RCT of zoledronic acid versus placebo.	BMD (Bone mineral denisty)	Results show that patients dosed later than 6 weeks after hip fracture had a greater increase in total hip and femoral neck BMD at 12 months compared to those given zoledronic acid within 6 weeks, and this difference appeared to be maintained at 36 months	There was no comment from the authors on reduction in healing rates in those who received treatment within 6 weeks of hip fracture. Conflict of interest as some of the authors are either employees, own stocks or received research grants from the manufacturing pharmaceutical company.
			Clinical fractures	reduced by similar amounts in both groups (33% in less than 6 weeks, and 37% in greater than 6 weeks

Comment(s)

The study concluded that the administration of bishosphonates to patients suffering a low-trauma hip fracture 2 wk or later after surgical repair increases hip BMD, induces significant reductions in the risk of subsequent clinical vertebral, nonvertebral, and hip fractures, and reduces mortality.

Clinical Bottom Line

The authors failed to comment on the effect of starting bisphosphonates as early as 2 weeks after fracture fixation, therefore it might be reasonable to wait for 6 weeks before restarting the treatment to give enough time for fracture healing.

References

1. Eriksen EF, Lyles KW, Colón-Emeric CS, Pieper CF, Magaziner JS, Adachi JD, Hyldstrup L, Recknor C, Nordsletten L, Lavecchia C, Hu H, Boonen S, Mesenbrink P Antifracture efficacy and reduction of mortality in relation to timing of the first dose of zoledronic acid after hip fracture