Differential Treatment of Osteoporosis with Medicaments

In the past, the term osteoporosis was used for manifest osteoporosis present­ ing with low bone mass and fractures. After consensus-conferences in the years 1991 and 1993 [1] osteoporosis is also the status of low bone mineral density with an increased risk for fractures – thus, the definition of osteoporosis of today is that of a systemic skeletal­ disease, characterised by diminished bone mass and impairment of the mi­ cro-architecture of the skeletal tissue leading to increased fragility, e.g. an increased risk of fractures. Now the definition of osteoporosis without frac­ tures is less precise. It depends on arbi­ trary limits of osteodensitometrical val­ ues. It is consensus to name the situation of BMD-values lower –2.5 standard­ deviations below the mean of young healthy adults (30 years) “osteoporo­ sis”, this is the so called T-value. The dilemma of this definition is evident for people of 80 years of age: about 80 % of them are “osteoporotic” without any proof that they all need treatment. Therefore, especially in the aged popu­ lation it is justified to relate the indi­ vidual BMD-value to the mean value of the age-group (Z-value). This could help to avoid blind over-treatment. This chapter deals with the drug treatment of manifest osteoporosis (pre­ senting with fractures), a condition with an absolute indication for treat­ ment. Depending on the individual risk­ situation these recommendations can be transferred to situations of lower bone mass (osteopenia), e.g. the range between –1 and –2.5 standard-devia­ tions (T-value), and to osteoporosis (–2.5 SD T-value) without fractures. The origin of osteoporosis can be primary or idiopathic – in those cases no leading risk factor or causal factor is evident. As a rule, postmenopausal osteoporosis in women also is defined as “idiopathic”, although the typical bone loss after the menopause contrib­ utes. The reason for the term idiopathic is the fact that all women pass the menopause, but only part of them (20%? more?) develop osteoporosis. Secondary osteoporoses (table 1) present with a leading risk or cause, for example hypogonadism in men, hy­ pogonadism before the age-period of the menopause in women (when estrogens normally are still produced), endocrinopathies like hypercortisolism, hyperparathyroidism and others.