We all encounter patients with osteoporosis in our daily practice - indeed the risk of osteoporotic fractures is increased in most endocrine disorders. The basic principles of diagnosing and treating osteoporosis and eliminating secondary causes remain simple and we should master them. However, providing truly excellent osteoporosis management is challenging and is much more than using the latest osteoporosis medication.
There are challenges. Few clinicians have easy access to gold standard invasive procedures such as transiliac bone biopsies. Others may lack later generation DXA with VFA, TBS, HSA or AFF screening modes or bone turnover markers. Risk stratification of patients can be done using FRAX(TM) or by other algorithms such as Garvan score or Q-fracture. New anabolic agents are in the immediate pipeline but the range of existing drugs we can prescribe and/or have patients reimbursed for differs between countries and between health services within the same country. The majority of our patients have one or more conditions that would have precluded them from participating in the RCTs that led to licensing of the drugs we have available. CKD is a particular challenge. Drug development in osteoporosis is slow as secondary endpoints such as BMD and bone turnover are not recognized in the way that lipids or HbA1c are in drug development in other areas. Osteoporosis trials are therefore large and long and new drugs arrive only slowly.
To provide a cutting edge osteoporosis service we should be able to accurately classify patients as high or low risk using evidence based tools, identify secondary causes, provide clear guidance to patients about their disease and treatment, be able to select, prescribe and monitor the most appropriate interventions in terms of effect and safety and make decisions together with the patients about when to begin, pause or re-start treatment.