Highlights of the American Society for Bone and Mineral Research 26th Annual Meeting -- Advances in the Treatment of Osteoporosis

Ego Seeman, MD

Disclosures

October 26, 2004

In This Article

I have confined my comments to advances and new insights into the treatment of osteoporosis. Reader, please be aware that this article and the content of the abstracts cited have not been peer-reviewed; so believe through a glass darkly.

Treating Fewer Persons at High Risk Later, Rather Than More Persons at Low Risk Earlier

The purpose of treatment is to prevent fractures. We have drugs that reduce fracture rates by about 50%, but whom should we treat and when? Eighty percent of fragility fractures in the community occur in women older than 60 years of age. The remaining 20% of fractures occur in 50- to 60-year-olds, and only about 15% come from women with osteoporosis because most women in this age group do not have osteoporosis. Schousboe (Park Nicollet Health Services, Minneapolis, Minnesota) and colleagues[1] reported that it is not cost-effective to treat women younger than 60 years of age with osteopenia and no fractures. Their analysis is based on Markov modeling, and the assumptions they make (listed in the abstract) are conservative: The population burden of fractures comes from where most people live -- ie, in the "bell" of the Gaussian distribution of bone mineral density (BMD) -- so the burden of events comes from the many at modest absolute risk with osteopenia. They are at risk, but few will fracture. We don't have any way of identifying those destined for fracture, so should we treat everyone to prevent a fracture in the small minority? The study authors argue that the cost do so is not sustainable. Not only is it not cost-effective, it needlessly exposes individuals to a drug.

Treating fewer individuals at high risk later in life ensures that those most likely to benefit from treatment receive it. This approach helps the high-risk individual, but it will not reduce the population burden of fractures. We have no solution to the population burden of fractures; orthopaedic surgeons will not be out of work.

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