Practice guidelines for the treatment of osteoporosis

History will probably describe this as a significant era for osteoporosis management, which has recently shifted from the laboratory and research clinic into mainstream clinical practice. It is timely, therefore, to provide practice guidelines for clinical use in this area; they must be developed carefully, however, so as to ensure that they are generated from reliable data. Furthermore, in current circumstances, management not only must be effective but also must aim for cost minimization; this is a difficult area in which little information is available. Also, in light of increased knowledge about skeletal medicine, complex cases should be considered for referral to an expert. The diagnosis of osteoporosis centers on two main steps: the identification of patients at risk and the estimation of bone density at two skeletal sites to help in ascertaining future fracture risk. At present, the main question in this approach centers on identifying the risk level threshold at which bone density should be evaluated. Although it is generally agreed that anyone with an atraumatic osteoporotic fracture will benefit from bone density estimation, the exact risk level for other, less easily defined indicators (e.g., cigarette smoking) is unclear. Once the diagnosis of osteoporosis is made, the cause must be elucidated by appropriate biochemical and imaging techniques. Appropriate therapy varies with the cause and level of risk. Although many treatments are currently available, including pharmacologic intervention, dietary changes, and exercise, they must be selected and adapted according to the needs of the individual patient, a process requiring both skill and patience.