Recent decades have seen the emergence of a number of major pharmacological interventions to reduce the risk of osteoporotic fracture. The most commonly used agents in Europe are the bisphosphonates, alendronate, risedronate and ibandronate; raloxifene; strontium ranelate; and agents derived from parathyroid hormone. Hormone replacement therapy was also used widely until recently. All of these agents have been shown to reduce the risk of vertebral fracture; some have been shown to also reduce the risk of non-vertebral fractures, most notably fracture of the proximal femur. The availability of these agents, coupled with increasing awareness of osteoporosis, has led to increased demand for cost-effective management of patients with the disorder. There is, at present, no universally accepted policy for population screening in Europe to identify patients with osteoporosis or those at risk of fracture. In the absence of such a policy, patients tend to be identified opportunistically using a case-finding strategy on the basis of a previous fragility fracture or the presence of significant risk factors, for example, low body mass index, parental history of hip fracture, glucocorticoid therapy, current smoking or alcohol intake, and a variety of secondary causes of osteoporosis. On the basis of these clinical risk factors, it is possible to model the absolute risk of osteoporotic fracture, and ascertain the extent to which additional estimation of bone mineral density will assist in a therapeutic decision. A group convened by the World Health Organisation has constructed a potential algorithm for case finding, based on knowledge of the interactions of the clinical risk factors, age and BMD. When applied to the population of the United Kingdom, this management algorithm provides for the treatment of post-menopausal women with a previous fragility fracture without the need for a BMD test (as prior fracture is a very strong risk factor for future fracture and is largely independent of BMD). For the other risk factors, treatment can be delivered cost-effectively in women aged 65 years or more, but in women below this age, further stratification of risk is indicated with a BMD test. Among women with a parental history of hip fracture, treatment becomes worthwhile with a BMD T score of –1SD; for woman taking long term glucocorticoids, a T score threshold of –2SD is appropriate; while for weaker risk factors (secondary causes of osteoporosis, smoking and alcohol consumption), an appropriate threshold is a T score of -2.5 SD. A host of health economic analyses suggests that this approach meets widely used cost-effectiveness criteria for chronic disease prevention in the United Kingdom. It is hoped that its promulgation will result in improved management of this important chronic disorder in western populations.
Disclosure of Interest None Declared
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