CHANGING OUR VIEW OF OSTEOPOROSIS.

Tremendous progress has been made over the past few years in the diagnosis and treatment of osteoporosis. It is now largely a treatable and preventable disease. Clinicians are now able to diagnose osteoporosis reliably, accurately, and noninvasively and can quantify its severity and monitor its progress. They also possess the necessary armamentarium to effectively treat it and significantly reduce the fracture risk.

The World Health Organization has issued diagnostic guidelines and the National Osteoporosis Foundation has issued treatment guidelines to help clinicians diagnose and treat the disease adequately. Unfortunately this progress has not been matched by a significant change in the practice of many clinicians. Osteoporosis is a major health problem associated with significant mortality and morbidity risks. In the United States, the annual health care cost is estimated to be between $10 and $15 billion.

Because osteoporosis is asymptomatic until a fracture occurs, the majority of patients are not aware of having the disease, and only a minority of patients is being treated. Even after a hip fracture, few patients are offered specific treatment for osteoporosis. This is regrettable, because the mortality and morbidity risks associated with osteoporosis are significant. Broy and colleagues presented evidence at the 64th Annual Scientific Meeting of the American College of Rheumatology in Philadelphia, Pa (October 29 to November 2, 2000), showing that, after a hip fracture, the 1-year mortality rate is about 24% in women and 50% in men. Moreover, about 50% of patients lose their physical independence, 25% require long-term nursing care, and 29% are expected to have a fracture of the contralateral hip within 20 years. The sequelae of hip fractures are indeed significant. The morbidity associated with vertebral fractures is often underestimated.

Osteoporosis satisfies most of the criteria of a disease in which prevention can be successful and effective. First, it is common. It affects about 40% of white, postmenopausal women. Non-white women and men are also affected by it, though less frequently than white women. A white, postmenopausal woman has about a 40% chance of having a fracture during her lifetime. Second, there is a long latency period between the time the disease is present (albeit asymptomatically) and the time it manifests itself clinically as loss of height, kyphosis, and fractures. This affords clinicians the time to detect and effectively treat the condition before it becomes symptomatic and complicated by fractures. Third, risk factors for osteoporosis have been identified. Many are reversible. This permits the institution of inexpensive and effective preventive measures. Fourth, we now have reliable and relatively inexpensive means to density those with osteoporosis before a fracture occurs, and more important still, we are able to identify those with low bone mineral density (ie, osteopenia) before the osteo-porotic stage is reached. This allows clinicians to target cases needing further investigation and prevention or treatment, and therefore increases the cost-effectiveness of a screening program. Finally, there are a number of medications approved for the prevention and treatment of osteoporosis. Most of these medications can significantly increase bone mineral density and reduce fracture risk. The challenging question that remains to be answered is how to develop a cost-effective screening program specifically targeted to those who are at risk.

There is a pressing need for clinicians to change their attitude toward osteoporosis. They need to sharpen their diagnostic skills and identify patients who have or are likely to have osteoporosis before a fracture occurs. There is also an equally important and pressing need to increase the public's awareness of the high prevalence of this disease and to recognize that the disease can now be prevented and treated. It is sobering to compare the effectiveness of available therapy to treat osteoporosis and reduce fracture risk to the effectiveness of medication to lower hyper-cholesterolemia and hypertension and reduce the risk of strokes, myocardial infarction, and heart failure. It is also sobering to compare the prevalence and impact of diseases such as breast cancer to those of osteoporosis. The mortality associated with both conditions is about the same, but the prevalence of osteoporosis is much higher than that of breast cancer, and the efforts made to diagnose breast cancer early far exceed those made t o diagnose osteoporosis or osteopenia.

This month's special feature is devoted to osteoporosis. Included in this section are highlights of the Southern Medical Association's Fourth Annual Conference on Osteoporosis, held in conjunction with the International Society of Clinical Densitometry meeting (Amelia Island, Fla, February 22-25, 2001), and highlights of a National Institutes of Health Consensus Conference held in March 2000. Also in this issue are a series of other features aimed at helping clinicians diagnose and better manage osteoporosis in their patients. Our hope is that the practice of most clinicians soon will reflect the tremendous progress that has been made over the past few years, and that they will realize osteoporosis is a largely preventable and treatable disease and that prevention is better and easier than cure.

Ronald C. Hamdy, MD, FRCP, FACP Editor