Technical Abstract The incidence rate of pelvic fractures increases dramatically with age, from 5.4 and 3.8 per 10,000 person- years in women and men aged 65 to 69 years to 93.5 and 44.5 per 10,000 person-years in women and men aged 90 years and older, respectively.3 Pelvic fractures are accompanied by severe pain, chronic immobility and loss of function and independence in the elderly.14 Pelvic fractures consume substantial healthcare resources, and based on administrative claims data, they are one of the most costly osteoporosis related fractures.4 Un-healed fractures, occurring in one-third of pelvic fracture patients at 3 months,16 can cause continued pain and impact mobility. With aging of the population, and expected concomitant increase in the incidence of pelvic fractures, there is a pressing need to find effective treatments that will accelerate healing. Fracture of the pubic ramus is most relevant and practical for randomized double-blinded placebo controlled study as this fracture is accompanied by severe pain and immobility in elderly, is associated with delayed fracture healing, and is almost always treated non-operatively. The current standard of care for pelvic fractures includes pain management, patient mobilization, and the prevention of complications associated with comorbid conditions. We hypothesize that development of a successful adjunctive therapy to accelerate fracture healing would lead to improved care and reduce both direct and indirect costs from pelvic fractures. In the proposed trial we will recruit women and men >65 years of age with acute osteoporosis-related pelvic fractures and address 3 specific aims over 3 months of treatment in a placebo controlled double blind study to determine if standard care and teriparatide 20 mcg/day versus placebo for pelvic fractures: 1. Results in earlier evidence of cortical bridging on routine radiographs followed by confirmatory Focus CT, a novel method to reduce radiation exposure from CT scans (primary outcome). 2. Leads to a faster reduction in pain as assessed by both the Numeric Rating Scale and a reduction in the use of narcotics (secondary outcome). 3. Leads more rapidly to improved functional outcome using a short physical performance battery to assess lower extremity function (secondary outcome). We will extend this study with 9 months of open label TPTD to determine if any potential differences between the placebo and TPTD groups during the 3 months of treatment are evident and persist over time, even in patients who use TPTD after the three month placebo controlled intervention. If TPTD can improve fracture healing, this study will have an impact on the treatment of persons with pelvic fracture who are not surgical candidates and often face severe pain, chronic immobility, and loss of function in the elderly. A positive finding of accelerated healing of pelvic fractures would also encourage study of TPTD for treatment of other osteoporotic fractures.
Osteoporosis is very common and 1 in 2 women and 1 in 4 men are likely to have an osteoporosis related fracture in their lifetime. Pelvic fractures are often a result of low-energy trauma, such as a fall from standing height. Pelvic fractures are associated with slow healing, chronic pain, limited mobility, and a delayed return to full function and normal activity. There is typically no surgery for pelvic fractures and the current treatment strategy includes pain management, patient mobilization, and the prevention of complications associated with comorbid conditions. Some prior studies indicate that an osteoporosis medication (teriparatide or Forteo) may help fractures to heal more quickly. However, there is not enough evidence to clinically use Forteo to heal pelvic fractures. Therefore, we will enroll 100 people in a clinical trial that would address whether healing of pelvic fractures is faster using one medication (teriparatide or Forteo) as compared to placebo (an inactive drug). We will evaluate pelvic fracture healing by CT scans, pain assessment, and by measuring the ability to perform various physical activities.
| Liu, Y; Levack, A E; Marty, E et al. (2018) Anabolic agents: what is beyond osteoporosis? Osteoporos Int 29:1009-1022 |
