The Australian Commission on Safety and Quality in Healthcare (ACSQHC) has just released the revised Hip Fracture Clinical Care Standard (2023). This publication provides guidance on pain management, time to surgery, mobilisation, and prevention of future fractures.
Almost 19,000 new hip fractures are thought to occur in Australia each year. These fractures typically occur in older individuals after a fall. This is often a life-changing event, significantly impacting future mobility and independence. In addition, one in four people who experience a hip fracture die within the following 12 months.
Key changes included in the revised standard include:
- The reduction in recommended time to surgery from 48 hours to 36 hours. This time is from the first presentation to a healthcare facility, even if transfer to another facility is required;
- The addition of statements to include delirium, nutrition, and frailty in assessments and management. Assessments for cognitive impairment are aligned with the Delirium Clinical Care Standard; and
- Changes to the quality statements regarding analgesia. This includes the use of nerve blocks and other changes to better align with the care described in the Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard.
Much of these updates have been informed by the Australian and New Zealand Hip Fracture Registry (ANZHFR) data. An interesting statistic from the ANZHFR Annual Report 2023 is that only 31% of patients presenting to Australian hospitals with a hip fracture were discharged on a bisphosphonate, denosumab, or teriparatide. Upon admission, 13% of patients were receiving therapy with one of these agents.
This issue is addressed in ‘Quality statement 6 – minimising the risk of another fracture’. Prior to discharge from hospital, patients should receive a falls and bone health assessment and management plan. When clinically appropriate, bone protection medicines are an important measure to reduce the risk of subsequent fractures.
Bone protection medicines include the following three categories:
- Bisphosphonates reduce bone resorption by binding to bone hydroxyapatite, particularly at sites with active resorption. As osteoclasts resorb bone, the bisphosphonate in the bone is released and impairs the ability of osteoclasts to continue bone resorption. There are a number of different bisphosphonates available, and they may be administered orally or parenterally.
- Denosumab is a monoclonal antibody. It also reduces bone resorption by inhibiting osteoclasts. However, it achieves this by binding to the RANK (receptor activator of nuclear factor-kappa B) ligand to prevent activation of the RANK receptor. This leads to decreased formation and activity of osteoclasts. Denosumab is administered subcutaneously on a six-monthly schedule.
- Teriparatide is the active fragment of human parathyroid hormone (PTH). The physiological actions of PTH include the regulation of bone metabolism, renal reabsorption of calcium and phosphate, and the intestinal absorption of calcium. Teriparatide has the same effects on the bones and kidneys as PTH and results in the promotion of bone formation and increased bone mineral density (BMD). Teriparatide is administered subcutaneously on a daily basis.
A summary of available bone protection medicines is shown in Table 1.
Table 1. Summary of bone protection medicines
|Drug||Route||Typical dose||Administration instructions|
|Alendronate||Oral||70mg weekly||· Swallow tablet whole in the morning with a full glass of plain water at least 30 minutes before food or drink. Remain upright during this time and until after you eat.
· Antacids, calcium, iron or mineral supplements must not be taken within 30 minutes of alendronate.
|Risedronate||Oral||5mg daily||· Swallow tablet whole in the morning with a full glass of plain water at least 30 minutes before food or drink. Remain upright during this time and until after you eat.
· Enteric-coated tablets (i.e. Actonel EC®) may be taken with or without food but the patient must still remain upright for 30 minutes after dose.
· Antacids, calcium, iron and mineral supplements must not be taken within 2 hours of risedronate.
|Zoledronic acid||IV||5mg annually||· Supplemental calcium and vitamin D are recommended after a low-trauma hip fracture.
· Studies mostly used a vitamin D loading dose (50,000-125,000 IU orally or IM) 2 weeks prior to infusion; then maintenance calcium (1,000-1,500mg daily) and vitamin D (800-1,200 IU daily).
|Denosumab||SC||60mg every 6 months||· Adequate calcium and vitamin D supplementation is required to reduce the risk of hypocalcaemia.
· Studies have used calcium 1,000 mg daily and at least 400 IU vitamin D daily.
|Teriparatide||SC||20mcg daily||· Recommended lifetime maximal duration of 24 months|
The ACSQHC advises that the revised clinical care standard maintains the same scope and goal as the original standard. Facilities that are currently using the 2016 Hip Fracture Clinical Care Standard may continue to use this for up to 12 months, but should transition to the updated version as soon as possible.
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