The treatment gap: The missed opportunities for osteoporosis therapy

Abstract

Despite substantial advances in delineation of the epidemiology, pathophysiology, risk assessment and treatment of osteoporosis over the last three decades, a substantial proportion of men and women at high risk of fracture remain untreated - the so-called "treatment gap". This review summarises the important patient-, physician- and policyrelated causes of this treatment gap, before discussing in greater detail: (a) the evidence base for the efficacy of bisphosphonates in osteoporosis; (b) recent evidence relating to the adverse effects of this widely used therapeutic class, most notably atypical femoral fracture and osteonecrosis of the jaw; (c) available strategies to improve both secondary and primary prevention pathways for the management of this disorder.

Keywords: Bisphosphonates; Osteoporosis; Treatment gap.

Figure 1

Proportion of postmenopausal European women at moderate, high and very high risk of osteoporotic fracture who are un-treated – the “treatment gap” according to EU27 country with the EU27 mean in grey Ref .

Figure 2

Frequency of use of anti-osteoporotic medication in England and Wales, 1990-2012. Orange squares denote incidence for women and blue diamonds the incidence for men.

Figure 3

Increase in frequency of prescribing anti-osteoporotic medication in UK following installment of secondary fracture prevention services nationwide. Percentage of anti-osteoporosis medication in the first year after index hip fracture among treatment naïve patients at baseline before and after the commencement of the secondary fracture prevention service (shown in grey). The blue line represents the actual (observed) increase in the proportion of patients receiving anti-osteoporosis medication before and after the instigation of the secondary fracture prevention service and the dotted line represents the modelled trajectory without the secondary fracture prevention service.

Figure 4

Results of MRC SCOOP Trial: Over 5 years, risk assessment using FRAX to target bisphosphonate therapy resulted in a 24% (p<0.01) reduction in the risk of hip fracture . The grey line shows the incidence of hip fracture in the non-screening (control) arm and the black line shows the lower incidence of hip fracture in the screening (experimental) arm.