Elaine Dennison (editor) - Osteoporosis Treatment: A Clinical Overview

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Osteoporosis is a disorder whose time has come (Fig. ). Recognised since antiquity, the impact of the condition through its association with age-related fractures; an understanding of its cellular and molecular pathology; development of risk assessment algorithms; and the discovery of a wide range of effective therapeutic interventions which attenuate bone loss and prevent fracture; have led over three decades to a conceptual transformation of our understanding of this disorder. The term osteoporosis was coined by pathologists in France and Germany during the middle decade of the nineteenth century. The description was morphologic, based upon reductions in cortical thickness and trabecular architecture. It was paralleled by observations on the patterns of occurrence of fractures in older people, made by orthopaedic surgeons in France and the United Kingdom. These pointed out the increasing frequency of fracture with advancing age; the greater predilection of osteoporosis in women; and early observations on seasonal variation in fracture incidence. Although these observations postulated a potential role for impaired bone strength in the aetiology of fracture, it remained for Fuller Albright, senior endocrinologist at Massachusetts General Hospital in the mid twentieth century, to link oestrogen deficiency in postmenopausal women with reduced bone mineral density and elevated fracture risk. The subsequent demonstration that postmenopausal oestrogen replacement reduced fracture risk, and that this effect might be mediated by an inhibitory influence on osteoclastic bone resorption, led to a resurgent interest in the non-invasive assessment of bone density, which culminated in the launch of dual-energy X-ray absorptiometry (DXA) in 1987.

The provision of this intermediary biomarker of fracture risk permitted the World Health Organization to define osteoporosis according to the population bone mineral density distribution (2.5 standard deviations below the young normal mean) in 1994. This heralded a quarter century of intensive pharmacologic innovation with release of a variety of antiresorptive and formation stimulating agents now available. The last decade has witnessed the delineation of national and international strategies to target these agents most effectively and thereby reduce the fracture burden in increasingly older populations. This volume attempts to integrate these innovations and to contextualise them within broad international attempts to combat musculoskeletal ageing and preserve physical function. These are entirely commensurate with the recently launched WHO Decade of Health Ageing.

Osteoporosis is a skeletal disorder characterised by low bone mass and microarchitectural deterioration of bone tissue with a consequent increase in the fragility of bone and consequent susceptibility to fracture []. Although the literature was relative sparce, the authors concluded that the direct costs associated with fragility fracture generally far outweigh the indirect costs , although the changing role of women in coming generations may increase indirect costs as they play an increasing role in the workplace.

This chapter will review the epidemiology of fragility fractures, and highlight the importance of fracture at a personal and societal level.

The definition of osteoporosis has been difficult. A definition based solely on bone mineral density (BMD) does not encompass all the risk factors for fracture, whereas a fracture-based definition will not enable identification of at risk population An expert panel convened by the World Health Organisation (WHO) in 1994 tried to resolve this issue resulting in the current, most widely used definition that encompasses both BMD and previous fracture [.