The management of osteoporosis.

The management of osteoporosis used to centre upon investigation and treatment of patients with fracture. The spectrum has now widened to include the detection of patients at high risk of fracture before a fracture occurs. This is best achieved by consideration of clinical risk factors and the selective use of bone densitometry. The frequency of osteoporotic fractures in elderly women is such that detailed investigation of such patients is often not necessary unless the patient's bone density is outside the normal range for age. When bone density is inexplicably low, secondary causes of osteoporosis should be sought by appropriate investigations. Fracture prevention involves a correction of lifestyle factors (stopping smoking, moderating alcohol intake etc.) and achieving a total calcium intake of 1-1.5 g/day. The first line for pharmacological intervention is hormone replacement therapy because of its proven efficacy and the extensive data available documenting its safety. The bisphosphonates have comparable effects on bone density and fractures in studies extending for up to 3 years, and are increasingly used, particularly in older patients and those reluctant to take hormone replacement therapy. Other available agents have significant drawbacks, either with respect to side-effects or inconsistent documentation of efficacy and should be used only in special circumstances.