In the past decade, we have witnessed a veritable revolution in osteoporosis diagnosis and therapeutics. Much of the success achieved has been motivated by an enhanced understanding of basic bone biology, a topic reviewed in a recent publication in the Arthritis Research & Therapy anniversary series. While bone density maintains great respect as one of the most valid and reliable measures of fracture risk, a renewed appreciation for the importance of other risk factors has led to new interest in AR models such as FRAX. New imaging approaches, including lateral VFA, have been added to the diagnostic armamentarium of bone health evaluation in an effort to identify fractures earlier. There is an increased appreciation of the severe consequences of prevalent fractures, not only of the hip but also of the much more common spine fractures. In particular, data substantiating the heightened risk of short-term re-fracture have increased the interest in secondary osteoporosis prevention. As international focus on osteoporosis has grown, accentuated diagnosis of alternate metabolic bone disorders has followed, and astute clinicians must be aware that there are many causes for low bone mass beyond osteoporosis. The use of sufficient calcium and attention to adequate vitamin D provide a necessary but often insufficient starting place for osteoporosis prevention and treatment. Aminobisphosphonates, taken orally or intravenously, have become the international mainstay of osteoporosis therapy. Questions exist about the very-long-term safety and the potential need for a drug holiday with some, if not all, of these compounds, despite their common use. Alternate therapeutic approaches that target suppression of bone resorption include historical use of sex steroids, SERMs, and now, less commonly, nasal calcitonin analogs. The mechanism of fracture reduction with daily strontium ranelate needs further study. Teriparatide is the first anabolic agent licensed for osteoporosis treatment but it must be given as a daily subcutaneous injection and used for a defined period of time. Therapeutic approaches on the horizon include biologic agents targeting RANKL, antibodies to sclerositin (a natural inhibitor of Wnt-mediated bone formation), and approaches to inhibit proteolytic enzymes such as catepsin K. While the past decade and a half has been a very exciting time in clinical osteoporosis care, the next decade should offer even greater promise for further improving our diagnostic and treatment approaches.
AR: absolute risk; BMD: bone mineral density; CI: confidence interval; DXA: dual-energy x-ray absorptiometry; ERT: estrogen replacement therapy; FIT: Fracture Intervention Trial; FRAX: Fracture Risk Assessment Tool; GI: gastrointestinal; ISCD: International Society of Clinical Densitometry; MORE: Multiple Outcomes of Raloxifene Evaluation; NOF: National Osteoporosis Foundation; NOGG: National Osteoporosis Guideline Group; NOS: National Osteoporosis Society; OPG: osteoprotegerin; PTH: parathyroid hormone; RANK: receptor activator of nuclear factor-kappa B; RANKL: receptor activator of nuclear factor-kappa B ligand; RR: relative risk; RRR: relative risk reduction; SERM: selective estrogen receptor modulator; VFA: vertebral fracture assessment; WHI: Women's Health Initiative; WHO: World Health Organization.
KGS is a consultant, speaker or research grant recipient for Amgen, Lilly, Merck, Novartis, Proctor and Gamble, and Sanofi-Aventis. PG declares that they have no competing interests.
Arthritis Res Ther. 2009;11(5):251 © 2009 BioMed Central, Ltd.
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Cite this: Progress in Osteoporosis and Fracture Prevention: Focus on Postmenopausal Women - Medscape - Oct 14, 2009.