Nat Rev Endocrinol. 2020 Mar 17. doi: 10.1038/s41574-020-0339-7. [Epub ahead of print]
Approximately 50% of women experience at least one bone fracture postmenopause. Current screening approaches target anti-fracture interventions to women aged >60 years who satisfy clinical risk and bone mineral density criteria for osteoporosis. Intervention is only recommended in 7-25% of those women screened currently, well short of the 50% who experience fractures. Large screening trials have not shown clinically significant decreases in the total fracture numbers. By contrast, six large clinical trials of anti-resorptive therapies (for example, bisphosphonates) have demonstrated substantial decreases in the number of fractures in women not identified as being at high risk of fracture. This finding suggests that broader use of generic bisphosphonates in women selected by age or fracture risk would result in a reduction in total fracture numbers, a strategy likely to be cost-effective. The utility of the current bone density definition of osteoporosis, which neither corresponds with who suffers fractures nor defines who should be treated, requires reappraisal.
In conclusion, I propose that broadening the use of generic bisphosphonates in older postmenopausal women by revising and simplifying intervention thresholds is justified by the available evidence. Under this broad intervention strategy, greater proportions of women would be offered treatment than under current screening scenarios. Cost-effectiveness thresholds should be used, rather than arbitrary definitions of osteoporosis based on BMD or fracture history. It is important to note that the proposed strategy will not eliminate the problem of fractures in older people as current medications have only partial efficacy; however, a broader intervention protocol does offer the possibility of beginning to address this major contributor to morbidity and mortality in our ageing population.