Selection of individuals for prevention of fractures due to bone fragility

Most patients with fractures go untreated because of the lack of awareness of osteoporosis. Treatment is indicated for women and men with osteoporosis and women and men with fractures with either osteoporosis or osteopenia be cause (a) fractures increase morbidity and mortality, (b) the burden of fra ctures is increasing because longevity is increasing, and (c) bone loss acc elerates, rather than decelerates in old age. The indication for drug thera py is less clear in women or men with osteopenia because drugs have not bee n proved to reduce fracture risk in this group. There is no evidence that t reating individuals with only risk factors reduces the fracture rate. Scree ning has not been shown to reduce the burden of fractures. Altering the bon e mineral density by a few percent in the population is likely to reduce th e number of fractures, but how this can be achieved is unknown. The rigorou sly investigated drugs reducing the spine fracture rate are alendronate, ra loxifene and risedronate. Calcium and vitamin D reduce hip fractures in nur sing home residents but not community-dwellers. In the community, only alen dronate and risedronate have been reported to reduce hip fractures in rando mized trials. The evidence for hormone replacement therapy is less satisfac tory. It is likely to reduce the number of spinal fractures, but its role i n hip fracture prevention is uncertain. Only alendronate has been reported to reduce spine fractures in men with osteoporosis. Evidence for the use of other drugs (calcitonin, fluoride, anabolic steroids and active vitamin D metabolites) in women or men is insufficient to justify their use.