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Underdiagnosis and Undertreatment of Osteoporosis: The Battle to Be Won.

CONTEXT
An expert opinion perspective on why osteoporosis is underdiagnosed and undertreated.


OBJECTIVE
To highlight the potential reasons for why osteoporosis is undertreated.


DESIGN
Literature review from PubMed, Plos One, and Science Direct search engines from 1900-2015 under terms: sub-trochanteric and atypical femur fractures, bisphosphonate clinical trial and bisphosphonate review articles, and treatment/under treatment of osteoporosis, as well as personal experience.


SETTING
Careful and objective review.


PATIENTS
Derived from reviews.


INTERVENTIONS
Bisphosphonates.


OUTCOMES
Atypical sub-trochanteric femur fractures.


RESULTS
Atypical sub-trochanteric femur fractures occur in both bisphosphonate and non-bisphosphonate users; and, bisphosphonate utilization has declined in temporal relationship with the reporting of these fractures associated with bisphosphonate use. There is no causality in this association and the benefit/risk ratio of bisphosphonates reducing all fracture risk vs the potential for the development of an atypical sub-trochanteric femur fracture is exceedingly in favor of bisphosphonate use in higher risk populations.


CONCLUSIONS
Treatments for osteoporosis should not be stopped (e.g. the "drug-holidays") in higher risk patients since the basic pathophysiology of osteoporosis continues; and, the evidence linking bisphosphonate use to causing atypical sub-trochanteric femur fractures is non-existent.