Atypical Femoral Fracture (AFF) is a rare complication of osteoporosis treatment. Based on a combination of systematic review and expert opinion the European Calcified Tissue Society (ECTS) have proposed a decision tree with considerations for medical management after AFF.
Figure 2. Decision tree with considerations for medical management after atypical femur fracture (AFF). aDefinition may vary across countries, eg, a hip BMD T-score ≤ –2.5 SD, older age (70–75 years), a recent fragility fracture, other strong risk factors for fracture, or a FRAX fracture risk score that is above country-specific thresholds (95). dRaloxifene or bazedoxifene are preferably prescribed in relatively young postmenopausal women who are at low risk of hip fractures and deep vein thrombosis (94), or in women in whom the use of teriparatide is contraindicated. eIn case of intolerance to SERMs, hormone replacement therapy or tibolone could be considered in women with a low risk of deep vein thrombosis and breast cancer, without a history of myocardial infarction or stroke (94). bSwitching denosumab to teriparatide may result in progressive BMD loss. cBe aware that antiresorptive therapy may be needed after stopping denosumab. fCalcitonin can be prescribed in patients who are not eligible for bisphosphonates, SERMs, hormone replacement therapy, tibolone, abaloparatide, or teriparatide.
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Reference:
Denise M van de Laarschot, Malachi J McKenna, Bo Abrahamsen, Bente Langdahl, Martine Cohen-Solal, Núria Guañabens, Richard Eastell, Stuart H Ralston, M Carola Zillikens, Medical Management of Patients After Atypical Femur Fractures: a Systematic Review and Recommendations From the European Calcified Tissue Society, The Journal of Clinical Endocrinology & Metabolism, Volume 105, Issue 5, May 2020, Pages 1682–1699, https://doi.org/10.1210/clinem/dgz295
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