What to Do When a Hip Breaks

Brittle bones are nothing new to an aging population: Americans suffer more than 300,000 hip fractures each year. And a person's likelihood of dying increases by 36 percent in the two years following a hip fracture. Karim Anton Calis, director of the drug information service at the National Institutes of Health and a clinical professor in the school of pharmacy at the University of Maryland, spoke with U.S. News about the critical problem of hip fracture patients often not getting optimal care—and what new research in the New England Journal of Medicine means for them.

What's wrong about the care hip-fracture patients tend to get?

After [surgical repair of] a hip fracture, many people surprisingly are not receiving optimal [follow-up] treatment. We have very compelling evidence to suggest that you really need pharmacologic intervention. People who have already sustained a hip fracture need better care in general. They need to ask their doctors, 'What are my options?'

What are their options?

Guidelines say the standard of care is a bisphosphonate drug. Optimal care also includes appropriate supplementation with calcium and vitamin D. Now, Kenneth Lyles of Duke University has found that once-yearly injections of the [bisphosphonate] drug zoledronic acid, known as Reclast, after surgery to repair a fractured hip reduced the risk of a subsequent fracture—over an average of two years of follow-up—by 35 percent and cut the risk of death by any cause by 28 percent when compared with a placebo. That's absolutely striking because now we're talking about something more important even than a fracture; we're talking about a human life.

How is it that vulnerable—and already injured—patients are getting overlooked when it comes to treatment?

A nontraumatic hip fracture—and I'm not talking about a motorcycle accident [injury]—is an indication that somebody has very serious bone disease. By definition they have osteoporosis. This is just pure speculation, but orthopedic surgeons are focusing on the surgery and what they can do actively to repair the hip, so maybe they're leaving that part of the care up to the primary care provider. I think the patient sort of falls through the cracks.

How might a zoledronic acid injection help these patients?

There are probably a number of advantages to using a drug like zoledronic acid. It is administered once yearly, [so] if you give somebody an injection they've at least gotten one full treatment, even if you then lose them to follow-up. They're covered for a year, so to speak. And a number of patients just can't tolerate the irritating effects of oral bisphosphonate on the gastrointestinal tract. But I don't think this [newfound benefit] is unique to zoledronic acid. I'm not promoting a particular drug product.

Do you think hormone replacement, nasal calcitonin, and selective estrogen-receptor modulator drugs like Evista may have a similar benefit as bisphosphonate drugs in preventing a second fracture or break?

There are a number of alternatives to [bisphosphonates]. Perhaps if we do the research—and I strenuously advocate additional research in this area—we might [find] that, in fact, there may be some agents that prove to be similar in efficacy to zoledronic acid or perhaps even superior. I think chances are that you'll probably see similar benefits with other [therapeutic] agents.