Elsevier

The Lancet

Volume 367, Issue 9527, 17–23 June 2006, Pages 2010-2018
The Lancet

Seminar
Osteoporosis

https://doi.org/10.1016/S0140-6736(06)68891-0Get rights and content

Summary

Osteoporosis is a serious public health issue. The past 10 years have seen great advances in our understanding of its epidemiology, pathophysiology, and treatment, and further advances are rapidly being made. Clinical assessment will probably evolve from decisions mainly being made on the basis of bone densitometry, to use of algorithms of absolute fracture risk. Biochemical markers of bone turnover are also likely to become more widely used. Bisphosphonates will probably remain the mainstay of therapy, but improved understanding of the optimum amount of remodelling suppression and duration of therapy will be important. At the same time, other diagnostic and therapeutic approaches, including biological agents, are likely to become more widespread.

Section snippets

Epidemiology

Osteoporosis is a skeletal disease characterised by low bone mass and microarchitectural deterioration with a resulting increase in bone fragility and hence susceptibility to fracture.1 It is an important public health issue because of the potentially devastating results2 and high cumulative rate of fractures; in white populations, about 50% of women and 20% of men older than 50 years will have a fragility fracture in their remaining lifetime.3 Indeed, in white women, the one in six lifetime

Pathophysiology

Osteoporotic fractures result from a combination of reduced bone strength and increased rate of falls. Although bone mineral density remains the best available non-invasive assessment of bone strength in routine clinical practice, many other skeletal characteristics also contribute to bone strength. These include bone macroarchitecture (shape and geometry), bone microarchitecture (both trabecular and cortical), matrix and mineral composition, as well as the degree of mineralisation, microdamage

Assessment of fracture risk

Since 1994, the benchmark for diagnosis of osteoporosis has been the assessment of bone mineral density. The ability to predict fracture risk from this measure is at least as good as if not better than the ability to predict heart disease risk from blood cholesterol concentrations and to predict stroke risk from blood pressure values.37 However, low bone mineral density alone does not mean an individual will have a fracture, and although the widely accepted diagnostic threshold of a T score

Management

Since most fractures happen as a result of falls, attention to reducing the risk of falls seems important. Although no studies are available that show that strategies to reduce the rate of falls will reduce fractures, the use of hip protectors to reduce the impact of falls has proven effective in high-risk individuals,41 although compliance remains an issue.42 At a mechanistic level, drugs can be considered in terms of whether they act mainly on bone resorption (antiresorptive agents) or on

Search strategy and selection criteria

The information in this Seminar is based on MEDLINE and PubMed searches with the search terms “osteoporosis” or “fracture” in combination with the keywords “calcium”, “vitamin D”, “bisphosphonates”, “selective estrogen receptor modulator”, “parathyroid hormone”, “strontium”, “RANKL”, “Receptors-LDL” or terms such as “randomized trials” or “meta-analyses”. We mainly selected papers from the past 5 years, but also included frequently referenced and highly regarded older papers. Some review

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