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
SeminarOsteoporosis
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
References (98)
- et al.
Epidemiology and outcomes of osteoporotic fractures
Lancet
(2002) - et al.
Magnitude and impact of osteoporosis and fractures
- et al.
Epidemiology of fractures in England and Wales
Bone
(2001) - et al.
A meta-analysis of previous fracture and subsequent fracture risk
Bone
(2004) - et al.
Mortality after all major types of osteoporotic fracture in men and women: an observational study
Lancet
(1999) - et al.
Prenatal and childhood influences on osteoporosis
Best Pract Res Clin Endocrinol Metab
(2002) - et al.
Gain in bone mineral mass in prepubertal girls 3.5 years after discontinuation of calcium supplementation: a follow-up study
Lancet
(2001) - et al.
The effects of estrogen on osteoprotegerin, RANKL, and estrogen receptor expression in human osteoblasts
Bone
(2003) - et al.
A mutation in the LDL receptor-related protein 5 gene results in the autosomal dominant high-bone-mass trait
Am J Hum Genet
(2002) - et al.
LDL receptor-related protein 5 (LRP5) affects bone accrual and eye development
Cell
(2001)