DOI: https://doi.org/https://doi.org/10.57187/smw.2023.40075
Considering the well-known high mortality of elderly patients with a recent major osteoporotic fracture, particularly at hip, Dr Suhm [1]challenges the recommendations from the Swiss Association against Osteoporosis (SVGO) for osteoporosis therapy in this population [2]. His position is surprising as it would imply that any therapy for secondary prevention of severe outcomes should be withdrawn from the oldest patient population at high risk of death. Yet, nobody would even think to let an old person with a myocardial infarction, for example, without treatment to prevent secondary CV events only because he/she would be too old and at high risk of dying eventually. Unless one could precisely identify which patients will refracture and not die, withdrawing osteoporosis therapy in the oldest fractured patient population will fail to protect the 10% who will eventually suffer from a second fracture within one year, according to the author’s own data, and the 20% or more who would eventually sustain a second fracture within 2 years. In fact, compared with younger individuals, a larger absolute risk reduction is observed in the elderly because of their higher baseline fracture risk, particularly when the fracture is recent. Therefore, the oldest patients will benefit the most from osteoporosis treatment. Moreover, preventing a fragility fracture from recurring, will not only spare further suffering, but potentially reduce the death rate. For instance, in the post-hip fracture HORIZON trial, administration of zoledronate within three months after a hip fracture not only reduced the rate of subsequent fractures by more than 30% within 3 years, but also reduced mortality by 28% [3].
For these reasons, we strongly encourage starting osteoporosis therapy as soon as possible in elderly individuals with a recent fragility fracture, while using clinical judgement on how to best apply treatment guidelines to individual cases.
Both authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflict of interest was disclosed.
1. Suhm N. Technical comment on: Ferrari S, et al. 2020 recommendations for osteoporosis treatment according to fracture risk from the Swiss Association against Osteoporosis (SVGO): Therapy of osteoporosis in the eldest geriatric patients – a plea for individualized decision-making. Swiss Med Wkly. 2023;153:40074. https://doi.org/10.57187/smw.2023.40074
2. Ferrari S, Lippuner K , Lamy O , Meier C . 2020 recommendations for osteoporosis treatment according to fracture risk from the Swiss Association against Osteoporosis (SVGO). Swiss Med Wkly. 2020 Sep;150(3940):w20352. https://doi.org/10.4414/smw.2020.20352
2. Lyles KW , Colón-Emeric CS , Magaziner JS , Adachi JD , Pieper CF , Mautalen C , et al.; HORIZON Recurrent Fracture Trial . Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med. 2007 Nov;357(18):1799–809. https://doi.org/10.1056/NEJMoa074941