Restarting Fosamax After Hip Fracture

Rationale for Treatment After Hip Fracture

The American College of Rheumatology recommends that patients with hip fractures have the highest post-fracture mortality risk, particularly in the first year, making secondary fracture prevention critical for survival 3
Alendronate is a first-choice agent for fracture prevention in postmenopausal women and men over 50 with osteoporosis, demonstrating reductions in vertebral fractures, nonvertebral fractures, and hip fractures in secondary prevention 1, 2
A hip fracture itself establishes the diagnosis of osteoporosis and represents "very high fracture risk" regardless of BMD T-score, warranting immediate pharmacologic intervention 3, 4

The American College of Rheumatology recommends calcium 1000-1200 mg/day and vitamin D 800 IU/day supplementation with alendronate 1, 2
Vitamin D supplementation at this dose is associated with 15-20% reduction in non-vertebral fractures and falls 1

The American Medical Association notes that alendronate is generally well tolerated when taken as recommended, with no statistically significant difference in serious adverse events compared to placebo in large clinical trials 6

The American College of Internal Medicine recommends continuing alendronate for 3-5 years initially, with reevaluation of fracture risk after 3-5 years to determine need for continued therapy 1, 7
Patients who remain at high risk, such as those with prior hip fracture, should continue treatment beyond 5 years 1

The American College of Rheumatology recommends zoledronic acid (intravenous) as an alternative agent for patients with contraindications to oral bisphosphonates, which reduces subsequent fractures 1, 2
Denosumab (subcutaneous) is appropriate for patients with oral intolerance, dementia, malabsorption, or non-compliance 1, 2
Teriparatide or romosozumab may be considered for very severe osteoporosis with multiple fractures 1, 3

The American College of Rheumatology recommends not delaying treatment waiting for "complete healing" beyond 2 weeks if wound is healing appropriately—the risk of subsequent fracture is highest in the first year 3
The American College of Rheumatology recommends not withholding treatment due to concerns about atypical fractures in the immediate post-hip fracture period—the absolute risk is extremely low and vastly outweighed by benefits 1, 2
The American College of Rheumatology recommends not forgetting calcium and vitamin D—these are essential components of all osteoporosis treatment regimens 1, 2