Acute back pain after osteoporotic fractures: Which medication?
A typical story
One of my patients had a history of osteoporosis, fell and developed low back pain. An x-ray detected a fracture in a vertebra, similar to the one shown in the figure. The pain was very strong, so she needed pain medication. Being over 80 years old, her primary care physician was concerned about potential side effects of opioids and non-steroidal anti-inflammatory drugs (NSAIDs). They therefore recommended acetaminophen, which provided only modest pain relief.
A public health problem
Osteoporosis and low bone mass affect over 50% of the USA population over 50 years old . Among individuals with low bone mass, vertebral fractures are extremely common. The estimated worldwide prevalence in women over 50 years old is 11-26% . In many patients, back pain after a fracture causes immobility, loss of independence, reduced social functioning, sleep disorder, depression, and long-term opioid use. Therefore, effective pain treatment is of paramount importance.
Pain medications: more harm than benefit?
Most patients experiencing pain after osteoporotic vertebral fracture are vulnerable. They are typically of older age, may be frail, and affected by co-morbidities. These factors increase substantially the risks associated with pain medications. NSAIDs are more likely to cause gastrointestinal, renal, and cardiac complications. In addition, there are concerns that NSAIDs may delay bone healing, and therefore prolong pain due to the fracture. In older adults, opioids increase the risk of falls and respiratory depression.
Despite the great importance of effective pain treatment, high-quality data on the efficacy, safety, and risk/benefit ratio of any medications for acute pain after osteoporotic fractures are lacking. In the absence of high quality data to support practice, this is one possible pharmacological approach to acute pain after an osteoporotic vertebral fracture.
Acetaminophen as first line.
NSAIDs or opioids, depending on individual risk profile: co-morbidities, age, concomitant use of sedating medications, past history of benefits/harms with NSAIDs and opioids.
Consideration of calcitonin.
Calcitonin for pain: underused?
Calcitonin is a hormone that decreases resorption of bone, and is FDA-approved for osteoporosis. Data show efficacy in acute pain after osteoporotic vertebral fractures . Most studies have used nasal spray 200 IU daily. UpToDate, a widely used decision support resource, recommends “2 to 4-week course or until the patient is able to get started on a more effective osteoporosis treatment regimen” . An NSAID or opioid can be added, if needed.
Given the concerns of using NSAIDs and opioids, it seems that calcitonin may be an excellent option, and is likely underused. Although high quality clinical trials are lacking, calcitonin could reduce the need for NSAIDs and opioids in the acute phase of an osteoporotic fracture, thereby improving the benefit/harm ratio of the pain medication regimen.
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Knopp-Sihota JA, Newburn-Cook CV, Homik J, Cummings GG, Voaklander D. Calcitonin for treating acute and chronic pain of recent and remote osteoporotic vertebral compression fractures: a systematic review and meta-analysis. Osteoporos Int. 2012; 23(1): 17-38.
Rosen HN, Walega DR. Osteoporotic thoracolumbar vertebral compression fractures: Clinical manifestations and treatment2020. UoToDate, https://www.uptodate.com.