General Considerations
It may be reasonable to reserve pharmacological therapy for nursing home residents at highest risk of hip fracture, such as those with prior fragility fracture or multiple risk factors (especially if any vitamin D insufficiency or deficiency has first been treated). Life expectancy should be taken into consideration. Careful consideration must be given to any contraindications to bisphosphonates or denosumab therapy.
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Primary Prevention
Assess fall risk (CaHFRiS tool) (level V). Assess risk (FREE tool, FRAX, or Garvan) (level V). Recommend BMD in patients at risk of osteoporosis prior to entry to residential aged-care facility (level III-2). Make sure that vitamin D, eGFR, and calcium levels are appropriate. Prescribe calcium/vitamin D, and multifactorial fall prevention (level I). Strongly consider subcutaneous denosumab or intravenous bisphosphonates in those at high risk of fracture (previous history of minimal trauma fracture and/or BMD criteria) (level I).
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Secondary Prevention
Treatment should be initiated in all residents with previous history of osteoporotic fractures (level II). Fractures should be actively documented (level V). Put on calcium/vitamin D, and implement multifactorial fall prevention (level I). Use of subcutaneous denosumab or intravenous bisphosphonate therapy is equally effective (level I). Recognize practical issues preventing successful uptake of oral bisphosphonates (level III-2). If oral bisphosphonates are still used, recommend education of nursing staff by pharmacists on oral bisphosphonate administration and dosing (level V). Subcutaneous denosumab and intravenous bisphosphonates are effective ways of overcoming dosing and compliance problems associated with oral bisphosphonates in this population (level V). Check 25(OH)D, Ca, and eGFR before using antiresorptives (level II). In patients with eGFR ≥35 mL/min, antiresorptive therapy with denosumab is a safer option (level II).
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Fractures Occurring on Antiresorptive Therapy
Consider using teriparatide if fracture occurs after 12 months of bisphosphonate therapy with T-score < −3 SD in patients with two or more fractures (level II). Consider denosumab as an alternative to oral bisphosphonate (level V). Strontium ranelate could be an alternative, taking into consideration recent warnings (level V).
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Side Effects of Antiresorptive Therapy
Oral bisphosphonates should not be used in patients with dysphagia or disordered swallowing (level I). Acute reaction post-IV bisphosphonate can be managed with prophylactic paracetamol therapy (level II). Osteonecrosis of the jaw is rare (between 1 in 10,000 and < 1 in 100,000 in patients on antiresorptive therapy for osteoporosis). In patients already on long-term bisphosphonates, close monitoring of predictive symptoms of atypical fractures is recommended with low threshold of x- ray if the resident complains of groin pain (level III).
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