Covid-19 to all CTF / FLS centers

The ongoing healthcare responses to COVID-19 is significantly disrupting the care of patients with non-COVID disorders, including patients with fragility fractures. In several centers, access to DXA/VFA was temporarily limited or stopped because of the COVID-19 pandemic. As services are beginning to be re-deployed, many teams will be reviewing and adapting historic FLS pathways to the ‘new normal’.

At the hospital level, without secondary fracture prevention, the avoidable recurrent fractures in the imminent risk period will only add to already stretched acute hospital systems.

In these exceptional circumstances, we encourage FLS centers to adopt the following simplified procedure:

  1. Keep a list of those patients with fragility fractures for further evaluation and treatment once services start returning to normal, ideally within 6 months after the fracture.
  2. Establish pathways in the trauma / orthopaedic centers to initiate appropriate osteoporosis therapy before discharge from the orthopaedic ward, to eligible patients above 65 years with a major fragility fracture of the hip, spine, humerus and pelvis without a DXA scan and in absence of contra-indications.
  3. As hospital services restart,  be pro-active in re-opening the DXA/VFA access as soon as possible

For all anti-osteoporotic medications (bisphosphonates, denosumab and teriparatide), patients are required to have a normal adjusted serum calcium and be calcium and vitamin D replete, according to national guidelines.

In healthcare systems where the initiation of AOM will be delayed by months due to the COVID19 pandemic, administration of zoledronate or denosumab during the inpatient stay can be considered.

Specifically, for zoledronate and denosumab:

  • Patients are required to have a normal adjusted serum calcium and be calcium and vitamin D replete according to local or national guidelines, usually taken as a serum 25OH vitamin D of at least 50 nmol/L.
  • Zoledronate is contra-indicated in those with a creatinine clearance of <35ml/min.
  • Zoledronate can be given within 2 weeks of a hip fracture if the patient is eligible. A fever may occur shortly after the zoledronate infusion and will respond well to paracetamol. This reaction is less severe after the second injection
  • Denosumab is cautioned in those with a creatinine clearance of <30 ml/min or receiving dialysis because of the risk of severe hypocalcaemia and should be managed according to local guidelines. Special attention should be given to ensure the next doses of denosumab are not missed.
  • Denosumab and zoledronate are considered safe with regard to COVID19. While zoledronate can be postponed in most circumstances, denosumab should not be postponed.
  • An alternative is to start with an oral bisphosphonate (alendronate 70 mg per week or risedronate 35 mg per week) together with calcium and vit D supplementation


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