Fracture Prevention Drugs Seem to be a Safe Bet

Crandall CJ, Newberry SJ, Diamant A, et al. Reviews: Comparative Effectiveness of Pharmacologic Treatments to Prevent Fractures: An Updated Systematic Review Annals of Internal Medicine 2014;161:711-723. doi:10.7326/M14-0317 18 November 2014    

Bischoff-Ferrari HA, Meyer O. Editorial: Comparative Effectiveness of Pharmacologic Treatments to Prevent Fractures: Is This All We Need to Know?Annals of Internal Medicine 2014;161:755-756. doi:10.7326/M14-1942 18 November 2014

There's currently enough “good-quality evidence” to support the use of several medications to prevent fractures, according to the authors of a systematic review.

They update their 2007 review, pointing out that there's now is more data on magnitude of effect, atypical femoral fracture, osteonecrosis of the jaw, and other adverse effects of bisphosphonates.

High-strength evidence shows that medications – including bisphosphonates, denosumab, and teriparatide-increase osteoporotic bone density and reduce fracture risk, with varying side effects, they explain. Relative risk reductions with these medications come in at 0.4 to 0.6 for vertebral fractures and 0.6 to 0.8 for nonvertebral fractures.

Among postmenopausal women with established osteoporosis, to prevent one vertebral fracture requires treating between 60 and 89 women with a bisphosphonate, denosumab, teriparatide, or raloxifene for 1 to 3 years. Between 50 and 60 patients need to be treated with a bisphosphonate, denosumab, or teriparatide to prevent one nonvertebral fracture.

However, bisphosphonates and possibly denosumab carry the risk for rare side effects, such as atypical subtrochanteric fracture or osteonecrosis of the jaw, the authors point out.

On the other hand, the new evidence allays early concerns about bisphosphonate-related atrial fibrillation or severe gastrointestinal side effects.

They note that evidence is weakest for the critical population of older adults (ages 75 and up), and is spare in men. Also, few studies compare drugs head-to-head.

The lack of data in older people represents a major weakness of this review, according to an accompanying editorial. The authors' conclusions may not apply to this population with the highest risk, it cautions.