Prescribing Advice for GPs

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Atypical fractures with alendronate

The New England Journal of Medicine has published a letter detailing some case reports of atypical low-trauma fractures in patients who have had prolonged treatment with alendronate.

The authors of the letter have identified 15 cases of unusual fractures in post menopausal women who had been treated with alendronate for an average of 5.4 years (SD 2.7 years). All fractures were subtrochanteric or proximal diaphyseal fractures and occurred following a fall from standing height or less.

Vitamin D and parathyroid hormone measurements were not taken as part of fracture care and bone mineral density was not assessed. Additionally, no data are presented to indicate rates of treatment compliance in these patients. The authors propose that a subgroup of the population may be more susceptible to the effects of prolonged suppression of bone turnover. They also suggest that, "additional studies are needed to characterise this subgroup and to establish a clear association between atypical fractures of the femur and prolonged bisphosphonate treatment".

Action: Clinicians should continue to follow the current NICE Guideline for secondary prevention of fractures in osteoporosis. Further investigation is required to understand this observed effect before clinical recommendations can be made. It would seem prudent to stop therapy in patients who sustain an atypical fracture while on treatment and submit a yellowcard report.

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