What's new in postmenopausal osteoporosis

The ability of bone to resist fracture is the best indicator of bone quality and is potentially related to several bone properties, including quality, turnover rate, microarchitecture, geometry, and mineralization. The U.S. Preventive Services Task Force recommends routine osteoporosis screening (by DXA) beginning at age 65 years for all women, and beginning at age 60 years for those at high risk. These recommendations are controversial, because no randomized trial results have shown that screening ultimately prevents fractures. Additional radiologic procedures may be helpful, particularly to define bone fractures. Several serum and urine biochemical tests are now available that provide an index of the overall rate of bone turnover and are usually characterized as those related primarily to bone formation or bone resorption. The results of clinical trials have shown that antiresorptive agents reduce fracture risk to varying degrees and that the magnitude of the reduction in fracture risk is proportional to the magnitude of changes in bone turnover and bone mineral density (BMD). The bisphosphonates are currently the preferred agents for the prevention and treatment of osteoporosis with the goal of reducing the risk of both vertebral and nonvertebral fractures. They are retained over time in the skeleton and may exert long-term effects. A 10-year course is safe and effective in women with high risk for fractures. A temporary stop may be considered after 5 years of treatment in less severe cases, on an individual basis. Calcitonin and raloxifene have no significant effect on the risk of hip and other nonvertebral fractures. Teriparatide, a synthetic 1-34 parathormone stimulates new bone formation, repairing architectural defects and reducing the risk of vertebral and all nonvertebral (but not hip) fractures in severe postmenopausal osteoporosis. Its administration is limited by time (no more than 2 years) and cost. The effect of vitamin D and calcium on the fracture's risk is controversial and its administration as the sole treatment is recommended mainly for elderly and other populations with Vitamin D deficiency. It is mandatory to supply the recommended vitamin D and calcium to the whole population independent of the need for therapy. Strontium ranelate appears to stimulate bone formation and reduce resorption and has been shown to reduce moderately vertebral and non-vertebral fractures in postmenopausal women with established osteoporosis. New medications are in development, including antiresorptive and bone formation stimulating agents.