Do current management strategies and guidelines adequately address fracture risk?

Deciding which patients are appropriate candidates for our effective osteoporosis therapies is a clinical challenge. Current guidelines for treating postmenopausal osteoporosis are based primarily on bone mineral density (BMD) measurements. There is consensus that postmenopausal women with osteoporosis, as defined by T-scores of -2.5 and lower, are at high risk of fracture and are candidates for therapy. However, many older adults without osteoporosis are at increased risk for fracture, and most fractures occur in women with higher T-scores. Current BMD-based guidelines are inconsistent regarding recommendations for treating women without osteoporosis. Fracture risk assessment is improved by combining BMD and other important risk factors for fracture, especially greater age and history of prior fracture. Strategies to estimate absolute fracture risk in individual patients are being developed. Revised treatment guidelines, based upon thresholds of absolute fracture risk, will provide the opportunity to identify and to treat those women who will most benefit from our therapies.