To the Editor I read with great interest the article by Dave et al¹ reporting that the initiation of antihypertensive medication is associated with elevated fracture risks. Although the study provides valuable insights, I wish to explore a crucial point.

Is there a difference in fracture frequency depending on the class or type of antihypertensive medication? Identifying which antihypertensive drugs are most likely to cause fractures would be invaluable, especially for older patients and those with low bone density. For instance, the Rotterdam study² showed a reduction in hip fractures with prolonged thiazide use (hazard ratio, 0.99; 95% CI, 0.97-0.99). However, thiazide-associated hyponatremia was associated with an increase in total fractures (incidence risk ratio, 1.44, 95% CI, 1.15-1.80; P = .001) in the participants, 86% of whom were older than 60 years.³ Short-term thiazide use (<90 days) after stroke increased vertebral fracture risk compared to nonuse (adjusted hazard ratio, 1.38; 95% CI, 1.02-1.88; P = .04),⁴ whereas longer-term use showed no difference in risk.⁵