Critical points in strategies for the diagnosis and treatment of osteoporosis.

Current treatment decisions for osteoporosis depend on the fracture risk calculated based on the results of comprehensive diagnostic procedures [clinical risk factors (CRF), densitometry (BMD), morphometry, and bone turnover markers (BTM)]. Recently developed fracture risk assessment tool (FRAX) represents an important new achievement as a 10-year fracture risk calculation based on femoral neck densitometry and age combined with independent clinical fracture risk factors. FRAX presents several options: FRAX BMI (body mass index) is advocated as a helpful screening tool to identify the group of patients with high fracture risk, independently of access to densitometry and FRAX, utilizing hip densitometry. In both cases, the probability of major fractures or hip fractures are calculated during performed diagnostic evaluations. Operating FRAX algorithm does not include spinal bone mineral density, which is its main limitation. With the aim of improvement of anti-fracture efficacy of therapeutic management of osteoporosis, we have extended our discussion to three integral elements of existent strategy: 1) screening outlines, 2) principles of drug selection, and 3) treatment benefit evaluation. Since osteoporosis is a chronic disease, long-term adherence to the treatment is important. The suitability of the drug, the patient's preference, tolerability, and convenience should all be considered. Anti-catabolic drugs are most appropriate in patients with high bone turnover, while anabolic drugs demonstrate efficacy irrespective of bone turnover. BMD measurement is most widely used for long-term assessment of the efficacy of osteoporosis treatment. The measurements of bone turnover markers (BTMs) can be considered a useful shortterm (at 3 months) monitoring tool in selected patients. In both BTM and BMD, the least significant change (LSC) method should be used for interpretation of the results. Fractures are not a reliable clinical endpoint for evaluating the effectiveness of therapy in individual patients because of their stochastic nature. If fractures occur, however, the need for drug change and additional non-pharmacological treatment (fall prevention, balance training, muscle strengthening) should always be considered.