The past 30 years has seen significant milestones in assessment and management of osteoporosis. These include the development of DXA and FRAX to identify individuals at high risk of fragility fracture and the development of interventions that have been shown to significantly decrease the risk of fracture in well-designed clinical trials. A major challenge has been how to apply these treatments. Measurements of bone mineral density (BMD) are used for diagnosis and for fracture risk prediction. Facilities for BMD testing are patchy and many European countries have inadequate resources to service the societal needs. In addition, BMD has poor sensitivity for the prediction of fracture so that the majority of fractures occur in individuals with T-scores >-2.5 SD. The development of FRAX has improved the sensitivity of fracture risk prediction and is now adopted in many assessment guidelins.
Despite these advances, there are a number of challenges to be faced. Of paramount importance is that few patients with a prior fracture and even less with osteoporosis alone actually receive treatment. In Europe, there is wide inter-country variation in the treatment of women at high risk for osteoporotic fractures. The treatment gap varies from 25% in Spain to 95% in Bulgaria. Large treatment gaps were identified in countries with populations at both high and low risk of fracture. In total in the EU, it is estimated that, out of the 18.4 million women that exceed the risk level in 2010, 10.6 million were untreated. These figures are conservative since an undetermined proportion of low-risk women will have received treatment. Moreover, the treatment gap is increasing in many countries. Thus the disease is under-recognised by the medical community.
Urgent action is required to address the under-recognition of osteoporosis and fragility fracture. Simple measures include:
The development of country-specific guidelines,
Piloting screening strategies in the elderly,
Identifying the determinants of imminent risk,
The development of fracture liaison services.
Whereas osteoporosis is recognized, worldwide, as a major Public Health issue, with one in two women and one in five men over the age of 50 years presenting a fragility fracture, a vast proportion of women at high risk remain untreated. Case-finding strategies prioritizing assessment of men and women with prior fracture are required to alleviate this problem.
Disclosure of Interest None declared