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Approaches to the targeting of treatment for osteoporosis

Nature Reviews Rheumatology volume 5, pages 425–431 (2009)Cite this article

Abstract

Fractures are a clinical consequence of osteoporosis, and represent a major cause of morbidity and mortality worldwide. Several treatments have been shown to decrease the risk of fracture, but problems arise in identifying individuals at high fracture risk so that treatments can be effectively targeted. The case for widespread population screening using bone mineral density testing is weak, as these tests lack sensitivity. Case-finding algorithms are available in many countries, but differ markedly in their approaches. Recent developments in fracture risk assessment include the availability of the FRAX® (WHO Collaborating Center for Bone Metabolic Disease, Sheffield, UK) tool, which integrates the weight of clinical risk factors for fracture risk with or without information on bone mineral density, and computes the 10-year probability of fracture. The tool increases sensitivity without trading specificity, and is now being used in the reappraisal of clinical guidelines.

Key Points

  • Despite a substantial burden of disease and the availability of treatments for osteoporosis, problems remain in identifying patients in whom treatment should be considered

  • Global strategies to improve bone mineral density (BMD) in the general population are untested

  • Screening and case-finding strategies using BMD testing are specific (they identify high-risk patients) but lack sensitivity (they miss many who will experience fractures)

  • Case finding can be enhanced by the consideration of clinical risk factors that provide information on fracture risk over and above that provided by BMD measurements

  • The FRAX® tool integrates information on fracture risk from clinical risk factors with or without BMD, and can be used to improve the targeting of treatment to individuals at high fracture risk

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Figure 1: Burden of disease, estimated as DALYs, in the Americas and Europe combined.
Figure 2: Case-finding strategies of the Royal College of Physicians in the UK and the National Osteoporosis Foundation in the US.
Figure 3: Management algorithm for the assessment of individuals at risk of fracture by the use of CRFs and BMD.1
Figure 4: Management chart for osteoporosis.

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Acknowledgements

Charles P. Vega, University of California, Irvine, CA is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.

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Authors and Affiliations

  1. WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK

    John A. Kanis, Eugene V. McCloskey, Helena Johansson & Anders Oden

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  1. John A. Kanis
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Correspondence to John A. Kanis.

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Kanis, J., McCloskey, E., Johansson, H. et al. Approaches to the targeting of treatment for osteoporosis. Nat Rev Rheumatol 5, 425–431 (2009). https://doi.org/10.1038/nrrheum.2009.139

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