The role of the primary care physician in diagnosis and management of osteoporosis.

It is estimated that 28,000,000 women in the United States have low bone mass (osteopenia) or osteoporosis. More than 1.5 million osteoporotic fractures occur annually. Because osteoporosis is asymptomatic until fracture occurs, early diagnosis requires both an awareness of risk and specific testing. The National Osteoporosis Foundation (NOF) has published guidelines for diagnosis and treatment, but these have important limitations. Bone mineral density (BMD) testing is the method of choice for diagnosis, and is more predictive of fracture risk than hypertension is of stroke or hypercholesterolemia is of myocardial infarction. Although the diagnosis of osteoporosis, as defined by the World Health Organization, is a T-score of < or =-2.5, the association between BMD and fracture risk is a continuous rather than threshold effect, and NOF guidelines suggest treating at higher T-scores, depending on risk factors. Important risk factors include age, current smoking, low body weight (<127 lbs.), maternal history of fracture, and personal history of fracture. Data from the National Osteoporosis Risk Assessment (NORA) study are presented, demonstrating the usefulness of peripheral BMD measurements in identifying postmenopausal women at risk of fracture. Several therapeutic options, including hormone replacement therapy, raloxifene, calcitonin, alendronate, and risendronate, are now available to the clinician. It can be argued that we currently have all necessary tools to eliminate osteoporosis and osteoporotic fracture.