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Invited Commentary
October 2016

Medication Review After a Fracture—Absolutely Essential

Author Affiliations
  • 1Department of Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston Massachusetts
  • 2Hebrew SeniorLife, Institute for Aging Research, Boston, Massachusetts
JAMA Intern Med. 2016;176(10):1539-1540. doi:10.1001/jamainternmed.2016.4822

Approximately 1 of every 2 women and 1 of every 4 men aged 50 years or older will experience a fracture in their remaining lifetime. In fact, in the United States, the annual number of osteoporotic fractures that occur exceeds the incidence of heart attack, stroke, and breast cancer combined. Morbidity and mortality is considerable following major osteoporotic fractures, particularly in individuals with hip fracture: 44% of individuals with a hip fracture are readmitted to the hospital, and 21% will die in the first year following the fracture.1 This readmission rate is nearly 2-fold greater than the readmission rate following elective joint replacement, and 1 year mortality is 2- to 4-fold greater than mortality observed in community dwellers of the same age and sex without fracture. Among survivors of a hip and other fracture, pain, depression, infections, functional decline, and subsequent fractures are all common complications leading to high rates of institutionalization.

Medication use may be a critically important determinant of patient outcomes following a fracture. In addition to individual medication class effects, polypharmacy and inappropriate drug prescribing during a hospitalization for fracture may be associated with an increased risk of mortality.2 Furthermore, reducing medications that increase the risk of falls is an effective means to prevent falls.3 Patients with fracture are at high risk of subsequent falls and fracture, and thus, reducing psychotropic medications and prescribing fracture-prevention medications are likely to reduce the risk of fractures in this high risk group.

In the study by Munson et al4 reported in the present issue of JAMA Internal Medicine, the authors examine the prevalence of prescription drug use in the 4 months before and after a fracture of the hip, humerus, or wrist in a sample of older, community-dwelling Medicare beneficiaries. The authors considered classes of medications associated with an increased risk of fracture via falls, decreased bone mineral density, or another mechanism. More than 85% of patients were still taking 1 or more drugs known to increase fracture risk in the 4 months following the fracture. Overall, the proportion of patients using drugs that increased risk of fracture was similar before and after the fracture: some patients discontinued drug use in the months following the fracture, while a similar number of patients were started on treatment with these drugs. However, within individual drug classes most strongly associated with fracture, it appeared that the prevalence of use was often greater after the fracture. For example, 3786 patients stopped taking a sedative after a fracture, whereas 8672 patients initiated sedative use in the months following the fracture. This same trend was observed for proton-pump inhibitors, selective serotonin reuptake inhibitor antidepressants, and antipsychotics. In contrast, the prevalence of oral glucocorticoid and thiazolidinedione use decreased in the months following a fracture. This suggests that clinicians more often taper nonpsychotropic medications following a fracture than they do psychotropic medications. Given the robust evidence linking psychotropic medications with falls5 and fractures, the lack of a decline in the use of these medications after a fracture is alarming.

Of equal concern, the authors reported a low prevalence of osteoporosis treatment following a fracture. Only 22% of individuals with a hip fracture received an oral bisphosphonate, the most commonly used medication to treat osteoporosis, in the 4 months after the fracture. Individuals with fracture are at high risk of subsequent fracture, particularly in the first year following a fracture.6 Bisphosphonates and other osteoporosis medications reduce the risk of fracture in as little as 6 to 12 months. Not treating patients with osteoporosis drugs after a fracture would be like discharging a patient after a myocardial infarction without drugs to prevent a subsequent infarction.

The findings of Munson et al4 suggest that far too often clinicians fail to perform a thoughtful medication review for patients with a fracture or to act on this review. A thoughtful review should include a discussion of reducing or eliminating medications associated with falls and bone loss whenever possible. Particular attention should be given to reduction of psychotropic medications, including benzodiazepines, non-benzodiazepine hypnotics, antidepressants, and antipsychotics. Educating patients and their families about the potential harms of psychotropic medications can be an effective strategy to reduce the use of psychotropic medications: a cluster-randomized trial of benzodiazepine use7 found that a simple educational pamphlet for consumers was able to successfully reduce or discontinue use in 38% of the participants in the intervention arm compared with 11% in the control arm. Fractures should serve as a trigger to initiate a discussion on the risks and benefits of medications associated with falls and bone loss.

After a fracture, a medication review should also give consideration to starting or continuing treatment with a medication for osteoporosis. The National Osteoporosis Foundation recommends that all adults aged 50 years or older with a hip fracture receive pharmacologic treatment for osteoporosis and that older adults with other fracture types receive osteoporosis screening and counseling. A recent study using commercial insurance claims8 concluded that by the end of 2013, only 15% of patients with a hip fracture received pharmacologic treatment for osteoporosis in the 6 months following the fracture (approximately 10% with bisphosphonates and 5% with other osteoporosis drugs). Munson et al4 report a somewhat larger proportion receiving treatment following a fracture, but it still highlights that a substantial treatment gap exists. It is imperative that researchers and clinicians work together to narrow this treatment gap to reduce secondary fractures and their devastating consequences.

While most clinicians would not dispute the importance of a medication review for patients with fracture, the question is who should conduct the review? Primary care clinicians are not commonly involved in postfracture management, and frequently patients have fewer in-person visits with these clinicians after a fracture. This makes it impractical for primary care clinicians to initiate timely medication reviews following a fracture. The transient nature of postfracture rehabilitation makes it equally unlikely that the responsibility for medication review will reside in the skilled nursing facility or as part of orthopedic follow-up. Clinicians in these settings may have limited resources or knowledge to initiate a comprehensive medication review. All clinicians who care for a patient following a fracture should review medications with special attention to psychotropic drugs and drugs that can prevent fractures. Use of fracture liaison services to optimize care after a fracture may be another successful strategy.9

There are obvious barriers to stopping or initiating treatment with medications following a fracture, including the challenges of working with multiple teams across care settings and the priority of managing the acute fracture complications. Patient preference is also an important factor that may influence medication changes. These data suggest that comprehensive medication reviews are infrequently being performed or acted on following a fracture, setting our patients up for subsequent falls and fractures. We challenge clinicians to work together to reduce the use of drugs associated with falls and fractures and to treat patients with osteoporosis medications to prevent subsequent fractures, whenever possible, in the weeks to months following a fracture.

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Article Information

Corresponding Author: Sarah D. Berry, MD, MPH, Institute for Aging Research, Hebrew SeniorLife, 1200 Centre St, Boston, MA 02131 (sarahberry@hsl.harvard.edu).

Published Online: August 22, 2016. doi:10.1001/jamainternmed.2016.4822.

Conflict of Interest Disclosures: Dr Berry receives grant funding from Amgen. Dr Kiel receives grant funding from Merck and Policy Analysis Inc, and he receives consulting fees from Merck. Dr Kiel also receives royalties from Wolters Kluwer and Springer for publications related to falls. No other conflicts are reported.

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