Critical illness: increased risk of fragility fracture and potential countermeasures

Critical illness and admission to an intensive care unit are associated with negative effects on bone and muscle metabolism. Driving factors are inflammation, medication (for instance glucocorticoids), malnutrition, and vitamin D deficiency as well as immobilization. Uncoupling of bone resorption and bone formation leads to loss of bone mass and stability. Deficits in muscle function increase the risk of falling. Thus, fracture risk is especially high during remobilization.Despite acute illness, it is important to counteract elevated fracture risk as soon as possible. Providing appropriate nutrition including sufficient protein and vitamin D as well as supervised exercising and early mobilization are essential for the protection of muscle and bone. Despite the fact that no osteoporosis drug is approved for the prevention or therapy of immobilization-induced osteoporosis, in special cases the treating physician may consider the initiation of an antiresorptive therapy with bisphosphonates or denosumab during the patient's stay in the intensive care unit. After discharge from the intensive care unit, it is important to evaluate the patient's risk for fragility fractures. If necessary, a bone-specific medication has to be implemented. Rehabilitation including progressive exercise and fall prevention strategies must be continued and, depending on the patient's needs, calcium and/or vitamin D supplemented. These are important modules for fracture prevention after a stay at an intensive care unit.