Osteoporosis in 2022: Care gaps to screening and personalised medicine

Abstract

Osteoporosis care has evolved markedly over the last 50 years, such that there are now an established clinical definition, validated methods of fracture risk assessment, and a range of effective pharmacological agents. However, it is apparent that both in the context of primary and secondary fracture prevention, there is a considerable gap between the population at high fracture risk and those actually receiving appropriate antiosteoporosis treatment. In this narrative review article, we document recent work describing the burden of disease, approaches to management, and service provision across Europe, emerging data on gaps in care, and existing/new ways in which these gaps may be addressed at the level of healthcare systems and policy. We conclude that although the field has come a long way in recent decades, there is still a long way to go, and a concerted, integrated effort is now required from all of us involved in this field to address these urgent issues to ensure the best possible outcomes for our patients.

Keywords: Epidemiology; Fracture; Osteoporosis; Policy; Treatment gap.

Figure 1

The treatment gap across Europe. The figure shows the percentage of women at high fracture risk who do not receive appropriate antiosteoporosis medication. Reproduced with permission from (8).

Figure 2

Meta-analysis of results from the SCOOP, ROSE and SOS trials of screening for fracture risk. Reused with permission from (70).

Figure 3

Personalisation of antiosteoporosis treatment according to baseline fracture risk. Initial risk assessment is performed using FRAX with clinical risk factors alone. FRAX probability in the red zone indicates very high risk, in which pathway C may be appropriate (anabolic agent followed by an inhibitor of bone resorption). FRAX probability in the green zone suggests low risk, in which pathway A should be followed, with advice to be given on lifestyle, calcium and vitamin D nutrition and menopausal hormonal treatment considered. FRAX probability in the orange zone (intermediate, between the upper assessment threshold, UAT, and lower assessment threshold, LAT) should be followed by BMD assessment and recalculation of FRAX probability including femoral neck BMD. After recalculation, risk may therefore be in the red zone (very high risk), orange zone (high risk, pathway B, which suggests initial antiresorptive therapy), reproduced with permission from (96).

Figure 4

Outline of a recommended approach to sequential therapy: in a patient with severe osteoporosis at high imminent risk of fracture following fracture risk assessment, a bone forming agent for 1-2 years is recommended (duration according to prescribing guidelines). Following this, bone-forming therapy, a consolidation period of antiresorptive therapy (such as a bisphosphonate or denosumab) is recommended. Monitoring, including assessment of treatment adherence and reassessment of fracture risk, is required. Reproduced with permission from (73).