Recent Management Controversies in Osteoporosis

Osteoporosis is a significant health concern that currently affects more than 10 million Americans, with an additional 34 million Americans at risk due to low bone mass. Osteoporotic fractures can lead to disabling pain, and nearly 30 % of patients with hip fractures require nursing home admission. In addition, 20 % of patients with hip fractures are no longer living one year after fracture. In 2011, the World Health Organization (WHO) defined osteoporosis as a skeletal disorder characterized by decreased bone strength, which is due to compromised bone strength and bone quality. However, bone quality remains difficult to measure therefore osteoporosis is diagnosed based in 1994 WHO guidelines using T-score based on bone mineral density (BMD). Osteoporosis is present when BMD lies 2.5 standard deviations (SDs) or more below the mean value for young healthy women (i.e., a T-score of <-2.5 SDs). Osteoporosis is further defined by the American Association of Clinical Endocrinologists (AACE) as a T-score of -2.5 or below in the spine (anteroposterior), femoral neck, or total hip, or the presence of fracture of the hip or spine (in the absence of other bone conditions).¹ Once osteoporosis has been diagnosed it is classified as either primary or secondary. Primary osteoporosis occurs later in life, in women often following the menopause. Secondary osteoporosis results from medications, concomitant conditions or disease processes² (a list of secondary causes can be seen in Table 1).¹ These secondary causes must be fully evaluated and excluded prior to initiating treatment.¹ There are several topics for debate in the current treatment of osteoporosis, which will be addressed in this article. These include the use of calcium and vitamin D supplements, duration of pharmacologic therapy, and the appropriate method for monitoring therapy.

Calcium Supplementation
Calcium and vitamin D are important in successful osteoporosis treatment. Randomized clinical trials have demonstrated that adequate calcium intake increased BMD and decreased the incidence of fractures.^3,4 In these trials,women who received calcium supplements of 1,000–1,200mg/day had fewer fractures than women who did not receive calcium supplementation. Guidelines therefore recommend a daily calcium intake of 800–1,200 mg/day, depending on age group, for adequate bone health.⁵ Over the past several years, however, research studies have demonstrated a possible link between calcium supplementation and increased risk of cardiovascular disease,⁶ making the choice of an appropriate dose of calcium the subject of increasing controversy.