IBMS BoneKEy | BoneKEy Watch

Preventing hip fractures: a controversial analysis


In this short analysis paper, Professor Järvinen and colleagues put forward an argument against using widespread use of anti-resorptive therapy to prevent hip fractures.

They voice the opinion that bone fragility, as assessed by bone mineral density measurements and use of the FRAX online hip fracture risk prediction tool, results in pharmacological treatment being offered to large numbers of women who fail to receive benefit from that therapy. Citing a systematic review of 33 RCTs, in which the absolute risk reduction for hip fracture over 3 years was 0.57%, they argue that treating 175 women for three years to avoid one hip fracture is not a good use of healthcare resources.

The overall conclusions of the analysis has received heavy criticism from other experts in the field. In a BMJ commentary, Professor Juliet Compston states that Järvinen et al. fail to recognise that, while many hip fractures are the result of a fall, the consequence of that fall is clearly connected with the underlying bone strength of the patient. She also comments that the analysis fails to differentiate between prevention of a first fracture and secondary prevention following a fracture event.Järvinen’s paper, she points out, also focuses solely on hip fractures and counters that other fractures, including vertebral fractures, occur frequently in elderly people and that there is clear evidence that these are due to bone fragility. The benefits of pharmacotherapy on secondary prevention these types of fractures is largely overlooked, she says. Her final conclusion is damning: “This paper is not an analysis, it is a biased and misrepresentative viewpoint. Publication of this misleading and nihilistic view of pharmacotherapy for osteoporosis does a disservice to the many millions of elderly people worldwide who suffer fragility fractures and to the scientific and patient organizations that have worked tirelessly over many years to improve their management.”

Editor’s comment: Single RCTs may have failed to produce clear evidence that bisphosphonates significantly decrease hip fractures after the age of 75, but rather than howling with the wolves, the authors should have performed a patient-level meta-analysis of trials that have included substantial subgroups of older women. Trails such as the HIP risedronate trial, the post-hip fracture HORIZON zoledronate trial, and the FREEDOM denosumab trial, which have all shown positive trends towards hip fractures reductions in the eldest of the elderly. It is important to note that lack of evidence in the absence of an appropriate analysis does not necessarily mean that anti-resorptives lack efficacy to reduce hip fractures in the elderly.

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