Osteoporosis: is there a rational approach to fracture prevention?

The most effective way to manage osteoporosis is to prevent fractures before they occur. To do this, a clinician needs to be aware of both the clinical risk factors that predispose a patient to an osteoporotic fracture and the patient's bone mineral density (BMD). An assessment of risk factors that increase fracture risk, including age, weight less than 125 pounds as an adult, family history of hip fracture, low-impact fractures as an adult, inability to rise up from a chair without using one's arms, presence of rheumatoid arthritis (RA), and use of glucocorticoid medication, in addition to low BMD, is necessary to assess fracture risk. Therefore, a complete history and BMD will improve the identification and treatment of patients at high risk of an osteoporotic fracture. Also, patients with systemic inflammatory diseases like RA or systemic lupus erythematosus have an increased risk of fracture owing to systemic inflammation independent of glucocorticoid use. These patients should be screened for osteoporotic risk factors, and BMD tests should be obtained. Treatment to prevent fractures should be initiated at a BMD (T score) <-1 to improve skeletal health in these patients. This review provides an update on the epidemiology of fractures, reviews fracture risk-factor assessment, and makes recommendations on how to screen patients and decide which patients would benefit from an intervention. Lastly, this review analyzes the new initiative by the World Health Organization (WHO) to assess fracture risk and new information on assessment of bone health in rheumatic disease patients.