Efficacy, cost, and aspects to take into account in the treatment of osteoporosis in the elderly

Efficacy of Antiresorptive Treatment in Osteoporotic Older Adults: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

OBJECTIVES

To investigate concerns surrounding the benefits of antiresorptive drugs in older adults, a systematic review was carried out to evaluate the efficacy of these treatments in the prevention of osteoporotic hip fractures in older adults.

DESIGN

a systematic review and meta-analysis of randomized clinical trials.

SETTING AND PARTICIPANTS

older adults ≥65 years with osteoporosis, with or without a previous fragility fracture. Studies with cancer-related and corticosteroid-induced osteoporosis, participants <65 years and no reported hip fracture were not included.

METHODS

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, ISI Web of Science and Scopus databases were searched. The primary outcome was hip fracture, and subgroup analysis (≥75 years, with different drug types and secondary prevention) and sensitivity analysis was carried out using a GRADE evaluation. Secondary outcomes were any type of fractures, vertebral fracture, bone markers and adverse events. The risk of bias was assessment with the Cochrane risk of bias tool.

RESULTS

A total of 12 randomised controlled trials (RCTs) qualified for this meta-analysis, with 36,196 participants. Antiresorptive drugs have a statistically significant effect on the prevention of hip fracture (RR=0.70; 95%CI 0.60 to 0.81), but with a moderate GRADE quality of evidence and a high number needed to treat (NNT) of 186. For other outcomes, there is a statistically significant effect, but with a low to moderate quality of evidence. Antiresorptives showed no reduction in the risk of hip fracture in people ≥75 years. The results for different drug types, secondary prevention and sensitivity analysis are similar to the main analyses and have the same concerns.

CONCLUSIONS

Antiresorptive drugs have a statistically significant effect on preventing hip fracture but with a moderate quality (unclear/high risk of bias) and high NNT (186). This small benefit disappears in those ≥75 years, but increases in secondary prevention. More RCTs in very old osteoporotic adults are needed.

Good practices in the recovery of ambulation in octogenarian women with hip fractures

OBJECTIVE

Determine good recovery practices for ambulation of octogenarian women after hospital discharge after being operated on for hip fracture.

METHODS

Prospective study during the second half of 2019, with 192 women (85.95 ± 5.1 years) with hip fracture. A medical history, fracture types, complications, surgical treatment, and assessment of the level of ambulation were recorded before and after six months of hospital discharge.

RESULTS

100 patients lived in the family home and 92 in an institutional center, 68.2% provided pertrochanteric fracture and a total of 3.7 comorbidities, all of them received spinal anesthesia and were admitted an average of 11.4 days. After six months, the patients showed a significant loss of functional independence with respect to the situation prior to the fracture, both for the ability to wander and for activities of daily living. It is noteworthy that the worst prognosis in the recovery of ambulation has to do with intermediate levels of ambulation and that the functional level of departure influences to a lesser extent than the place where they perform the recovery.

CONCLUSIONS

Age is a factor that influences the recovery of hip fracture, but there are other influential factors since patients who remain in the family home have a better functional prognosis than those who recover in institutionalized centers, after six months of hospital discharge.

Best Practice Framework of Fracture Liaison Services in Spain and their coordination with Primary Care

The coordination of Fracture Liaison Services (FLS) with Primary Care (PC) is necessary for the continuity of care of patients with fragility fractures. This study proposes a Best Practice Framework (BPF) and performance indicators for the implementation and follow-up of FLS-PC coordination in clinical practice in Spain.

PURPOSE

To develop a BPF for the coordination of FLS with PC in Spain and to improve the continuity of care for patients with fragility fractures.

METHODS

A Steering Committee selected experts from seven Spanish FLS and related PC doctors and nurses to participate in a best practice workshop. Selection criteria were an active FLS with an identified champion and prior contact with PC centres linked to the hospital. The main aim of the workshop was to review current FLS practices in Spain and their integration with PC. A BPF document with processes, tools, roles, and metrics was then generated.

RESULTS

Spanish FLS consists of a multidisciplinary team of physicians/nurses but with low participation of other professionals and PC staff. Evaluation and treatment strategies are widely variable. Four desired standards were agreed upon: (1) Effective channels for FLS-PC communication; (2) minimum contents of an FLS clinical report and its delivery to PC; (3) adherence monitoring 3 months after FLS baseline visit; and (4) follow-up by PC. Proposed key performance indicators are (a) number of FLS-PC communications, including consensus protocols; (b) confirmation FLS report received by PC; (c) medical/nursing PC appointment after FLS report received; and (d) number of training sessions in PC.

CONCLUSIONS

The BPF provides a comprehensive approach for FLS-PC coordination in Spain, to promote the continuity of care in patients with fragility fractures and improve secondary prevention. The implementation of BPF recommendations and performance indicator tracking will benchmark best FLS practices in the future.

Stem cells in Osteoporosis: From Biology to New Therapeutic Approaches

Osteoporosis is a systemic disease that affects the skeleton, causing reduction of bone density and mass, resulting in destruction of bone microstructure and increased risk of bone fractures. Since osteoporosis is a disease affecting the elderly and the aging of the world's population is constantly increasing, it is expected that the incidence of osteoporosis and its financial burden on the insurance systems will increase continuously and there is a need for more understanding this condition in order to prevent and/or treat it. At present, available drug therapy for osteoporosis primarily targets the inhibition of bone resorption and agents that promote bone mineralization, designed to slow disease progression. Safe and predictable pharmaceutical means to increase bone formation have been elusive. Stem cell therapy of osteoporosis, as a therapeutic strategy, offers the promise of an increase in osteoblast differentiation and thus reversing the shift towards bone resorption in osteoporosis. This review is focused on the current views regarding the implication of the stem cells in the cellular and physiologic mechanisms of osteoporosis and discusses data obtained from stem cell-based therapies of osteoporosis in experimental animal models and the possibility of their future application in clinical trials.