The guidelines for treating osteoporosis do not differentiate between osteoporotic patients who have had a prior fracture and those who have not. They only recommend that patients with prior fractures should be treated. For example, the drugs recommended as first- and second-line are the same.
On the other hand, there are well-defined criteria for changingmedication in case of treatment failure. The occurrence of one or more fractures during treatment is considered as treatment failure. However, there is no indication that these criteria may be used in patients with prior fractures without pretreatment.
The site of the fracture makes a difference. A vertebral fracture increases the chance of another fracture 4-fold; while a fractured wrist increases it 2-fold. Some fracture liaison services (FLS) consider that the cost-benefit balance of starting secondary prevention after a fractured wrist is not positive.
Others include this type of patient (which is what I usually do). Ankle fractures, in this respect, are comparable to wrist fractures. However, there are no questions in relation to fractures of the hip and proximal humerus. Recommendations for physical activity and rehabilitation are directly linked to the type of prior fracture and the possible limitations its sequelae can impose.
Prevention of falls is critical in both primary and secondary prevention, as is ruling out the causes of secondary osteoporosis. Long-term safety and effective antifracture drugs must be used and adequate calcium and vitamin D supplementation required. What must differ in our approach to a patient who has already had an osteoporotic low-trauma fracture compared with another who had no fracture is basically our attitude. The historic low adherence to antiosteoporotic treatment, which in primary prevention is a problem, becomes a catastrophe in secondary prevention because of the high risk of new fractures. The use of oral bisphosphonates is associated with low adherence. In the case of generic alendronate (which is the most used), it is even more obvious and the fractures that occur as a result of this notorious noncompliance are not taken into account when evaluating this apparently cheaper drug.
One of the strategies recommended by the Committee of Scientific Advisors of the IOF (International Osteoporosis Foundation), when referring to treatment failure in osteoporosis, is to replace an oral drug by an injected drug. There is no doubt that this recommendation is given because injected drugs are used quarterly, semi-annually, or annually, which improves treatment adherence.
The new status quo (the new fracture) requires this type of intervention. However, adherence is still below the desired level. One of the reasons for this lies in the habit of reviewing patients only once per year. There is no other serious illness (and osteoporosis is a serious illness; osteoporosis with fractures even more so) for which the follow-up is only done on an annual basis. This is not the case, for example, for diabetes, arterial hypertension, or heart disease.
The routine in our FLS is that there is a visit every four months in the first year; in the following years, the review is every six months. At each visit blood samples are collected to assess total serum calcium and 25OH vitamin D.
Motivating patients is of the utmost importance. The results of bone densitometry, with their small positive variations, often discourage patients. However, adequate vitamin D replacement demonstrates encouraging and motivating results. Since the majority of fractures occur in the first two years following a fracture, maintaining motivation and adherence is crucial at least in this period.