J C Munson1,2,3, J P W Bynum4,5,6,7, J-E Bell4,8, C McDonough9, Q Wang4, T Tosteson4,10, A N A Tosteson4,5. 1. The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA. Jeffrey.C.Munson@hitchcock.org. 2. Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA. Jeffrey.C.Munson@hitchcock.org. 3. Department of Medicine, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Suite 5C, Lebanon, NH, 03756, USA. Jeffrey.C.Munson@hitchcock.org. 4. The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA. 5. Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA. 6. Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA. 7. Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI, USA. 8. Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA. 9. School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA, USA. 10. Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
Abstract
Drugs that increase the risk of fracture are commonly prescribed to survivors of a fragility fracture. This study shows that starting new high-risk medications after fracture increases the risk of a second, potentially preventable fracture. For most drug classes, however, it is safe to continue medications taken before the fracture. INTRODUCTION: Most patients who survive a fragility fracture are subsequently exposed to prescription drugs that have been linked to increased fracture risk. This study was designed to quantify the extent to which current prescribing practices result in potentially preventable second fractures. METHODS: We analyzed a cohort of 138,526 Medicare beneficiaries who returned to the community after a fragility fracture. Post-fracture drug use was defined using retail pharmacy fills. The risk of second fracture associated with individual drug classes was analyzed using Cox proportional hazard models. Data were further analyzed to determine whether there is a difference in risk between continuing previous therapy and initiating new therapy after fracture. RESULTS: Many drug classes previously identified as increasing fracture risk were not associated with increased fracture risk in this cohort. Discontinuing therapy at the time of fracture was only beneficial for patients taking selective serotonin reuptake inhibitors; however, initiating therapy in previous non-users increased second fracture risk for five classes of drugs (selective serotonin reuptake inhibitors, tricyclic antidepressants, antipsychotics, proton pump inhibitors, and non-benzodiazepine hypnotics). CONCLUSION: Discontinuing high-risk drugs after fracture was not generally protective against subsequent fractures. Preventing the addition of new medications may result in greater improvements in post-fracture care.
Drugs that increase the risk of fracture are commonly prescribed to survivors of a fragility fracture. This study shows that starting new high-risk medications after fracture increases the risk of a second, potentially preventable fracture. For most drug classes, however, it is safe to continue medications taken before the fracture. INTRODUCTION: Most patients who survive a fragility fracture are subsequently exposed to prescription drugs that have been linked to increased fracture risk. This study was designed to quantify the extent to which current prescribing practices result in potentially preventable second fractures. METHODS: We analyzed a cohort of 138,526 Medicare beneficiaries who returned to the community after a fragility fracture. Post-fracture drug use was defined using retail pharmacy fills. The risk of second fracture associated with individual drug classes was analyzed using Cox proportional hazard models. Data were further analyzed to determine whether there is a difference in risk between continuing previous therapy and initiating new therapy after fracture. RESULTS: Many drug classes previously identified as increasing fracture risk were not associated with increased fracture risk in this cohort. Discontinuing therapy at the time of fracture was only beneficial for patients taking selective serotonin reuptake inhibitors; however, initiating therapy in previous non-users increased second fracture risk for five classes of drugs (selective serotonin reuptake inhibitors, tricyclic antidepressants, antipsychotics, proton pump inhibitors, and non-benzodiazepine hypnotics). CONCLUSION: Discontinuing high-risk drugs after fracture was not generally protective against subsequent fractures. Preventing the addition of new medications may result in greater improvements in post-fracture care.
Entities:
Keywords:
Medicare; Osteoporosis; Pharmacoepidemiology; Second fracture
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