An Evidence-based Approach to Osteoporosis Management

In an effort to step up fracture prevention efforts, the National Osteoporosis Foundation (NOF) has released a revised guide on the comprehensive management of osteoporosis, which includes detailed recommendations on assessment and diagnosis, in addition to a summation of treatment options. This article includes updated NOF recommendations, pharmacoeconomic considerations of assessing fracture risk, and a review of currently available antiresorptive and anabolic agents. Essentially, the NOF recommends bone mineral density (BMD) testing in all women aged 65 and older and in men aged 70 and older. Beyond BMD measurements, additional skeletal health assessment techniques are available, one of which is the World Health Organization fracture risk algorithm (FRAX), which calculates the 10-year probability of a major fracture and is thus used to identify highrisk candidates for pharmacologic intervention. Currently available treatments are largely assessed on their efficacy in reducing vertebral and, most importantly, nonvertebral (hip) fractures, with bisphosphonates having the most abundant data on fracture reduction. (Adv Stud Pharm . 2008;5(7):215-219) E fforts to reduce the long-term consequences of osteoporosis are dependent not only on the effectiveness of current pharmacologic therapies, but most critically, on the ability to identify and treat at-risk individuals before their bone mineral density (BMD) becomes dangerously low and fractures become inevitable. The majority of fractures actually occur in patients with low bone mass rather than osteoporosis, and although currently available treatments are effective in secondary prevention of subsequent fractures, they cannot reverse the disability and mortality that is well known to accompany hip fractures. As a reflection of the essential need to step up fracture prevention efforts, especially in the face of a rapidly growing elderly population, the National Osteoporosis Foundation (NOF) has, in collaboration with other societies (eg, World Health Organization [WHO]), released a revised guide on the comprehensive management of osteoporosis. Since publication of the original guide in 1999, the NOF has ascertained that many patients are not given adequate prevention information and appropriate testing, therefore, many of the new recommendations, particularly those pertaining to risk assessment and diagnostic testing, are based largely on the WHO 10-year fracture model (discussed later in this article) and an accompanying economic analysis. The following discussion focuses on key NOF recommendations.