Fracture Reduction

Approach to Fracture Reduction in PLWH
Reducing risk of fractures

Persons at high risk of fractures:

• Frail or sarcopenic persons
• Previous fracture, particularly if recent
• Low BMD

• Aim to decrease falls by addressing frailty and fall risks(i)

• Consider bisphosphonate(ii)
   - Treatment based on fracture history and FRAX score (see section on Bone Disease Screening and Diagnosis)
   - Ensure adequate calcium and vitamin D intake(iii)

• Consider choice of ARV in those at high risk of fractures(iv)
   - No significant interactions between bisphosphonates and ARVs

• Optimal management of frailty includes optimising nutrition, exercise (aerobic and resistance training), see section on frailty

• In complicated cases (e.g. young men, premenopausal women, recurrent fracture despite bone protective therapy), refer to osteoporosis specialist

• If on bisphosphonate treatment, repeat DXA after 2 years. Persons without response to treatment refer to osteoporosis specialist for second line treatment. Re-assess need for continued treatment after 3-5 years

  1. Falls Risk Assessment Tool (FRAT), See falls-risk-assessment-tool and  Diagnosis and management of vitamin D deficiency
  2. Bisphosphonate treatment with either of alendronate 70 mg once weekly po; risedronate 35 mg once weekly po; ibandronate 150 mg po once a month or 3 mg iv every 3 months; zoledronate 5 mg by iv infusion once yearly
  3. see Diagnosis and management of Vitamin D deficiency
  4. See Bone disease screening and diagnosis; some ARVs can affect BMD but relationship to increased fractures are not well defined. Consider relative risk/benefit of using these agents in persons with high fracture risk