For older adults who suffer a fragility fracture, the weeks immediately following the break represent the highest window of risk for a second, often more devastating, fracture. Yet a deeply entrenched clinical hesitancy — rooted in theoretical concern rather than robust evidence — routinely delays the very treatments most likely to prevent that cascade. Understanding why this gap persists, and what the evidence actually shows, matters enormously for the millions of older adults who fracture a hip or vertebra each year.
The commentary in The Lancet Healthy Longevity directly confronts the widespread clinical assumption that antiresorptive medications, particularly bisphosphonates and denosumab, impair bone healing when initiated shortly after fracture. The concern centers on the biological logic that suppressing osteoclast activity — the mechanism by which these drugs reduce bone resorption — might interfere with the remodeling phase of fracture repair. However, the available clinical and preclinical evidence does not substantiate meaningful delays in fracture union at therapeutic doses. The piece argues that anabolic agents such as teriparatide and romosozumab may carry distinct mechanistic advantages in the acute post-fracture period, given their bone-formation-first profiles, but that withholding any antiosteoporotic therapy pending healing represents a clinically unjustified trade-off.
This commentary enters a long-running debate that has real consequences for secondary fracture prevention programs worldwide. The "imminent fracture risk" concept — the dramatically elevated re-fracture probability in the 12 months following an index fracture — is well-established in epidemiology, yet Fracture Liaison Services still report substantial treatment gaps. The argument here is essentially that pharmacological caution is being misapplied: the theoretical harm of early antiresorptive use is small and unproven, while the documented harm of delayed treatment is substantial and measurable. A key limitation is that this is expert commentary, not a meta-analysis or trial; clinicians should weigh it alongside systematic reviews comparing fracture-healing outcomes across drug classes. Still, as a call to reframe clinical defaults, it is timely and practically significant for geriatric and orthopedic practice.
