Orthopaedics  |  Fragility Fractures Pathway - Reduce Adverse Medication


Fragility Fractures Pathway - Reduce Adverse Medication

Many medications are known or suspected to reduce bone density although the impact of this on clinical fracture rates varies and is the subject of ongoing scientific debate. The association is stronger and better quantified for some of the following classes (aromatase inhibitors, glucocorticoids, GnRH agonists) than others. Suggestions for management are:

Medicine class Medications Suggested approach
Anticonvulsants Phenytoin, carbamazepine, primidone, phenobarbitone, sodium valproate Consider changing to newer anticonvulsants or give vitamin D (1 x 1.25mg (50,000 IU) tablet fortnightly rather than monthly)
Aromatase inhibitors Anastrozole, letrozole, exemestane Supplement calcium and vitamin D if dietary intake inadequate; for high-risk patients consider co-prescribing anti-resorptive medicine e.g. bisphosphonate
Depot medroxyprogesterone Acetate (DMPA) Depo Provera Impact depends on age and duration. Ensure adequate calcium and vitamin D intake, encourage weight-bearing exercise
Glucocorticoids Prednisone Ensure lowest effective dose and duration, consider co-prescribing anti-resorptive medicine e.g. bisphosphonate
GnRH agonists Leuprorelin (Lucrin®), goserelin (Zoladex®) As for aromatase inhibitors
Long term heparin use - Dose and duration related (>15,000 units unfractionated heparin per day for >3 months). Risk may be lower with LMWH than UFH
Pioglitazone - Contraindicated in osteoporosis – do not use
PPIs Lansoprazole, omeprazole, pantoprazole Keep dose and duration as low as possible (increased risk of fracture after 5 years); consider change to ranitidine or famotidine
SSRI and SNRI antidepressants Citalopram, fluoxetine, paroxetine, sertraline, venlafaxine, mirtazapine Regularly review ongoing need for antidepressant
Thyroxine - Ensure TSH within normal range and not ‘over-replaced’

This medication review and rationalisation should be a routine part of osteoporosis management as should the reduction of medication likely to aggravate risk of falls (see Bay Navigator pathway for Falls Prevention - to be available later). Seek advice if unsure via Fragility Fracture pathway group member Pauline McQuoid, phone 021 864 996 or by utilising the 'advice only' tab of the HIA eReferral form.

Last updated : Tuesday, November 21, 2017
Next review date : Wednesday, November 21,2018

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