GERIATRIC THERAPEUTICS
Editors: Michael Woodward, Head, Aged and Residential Care Services, Stephen Campbell, Consultant Geriatrician, Rohan
Elliott, Clinical Pharmacist, Graeme Vernon, Senior Drug Information Pharmacist, Francine Tanner, Clinical Pharmacist,
Austin Health; and Robyn Saunders, Consultant Pharmacist, Victoria.
Management of Osteoporosis in Older People
Charles A Inderjeeth, Kate E Poland
ABSTRACT
Table 1. Risk factors for osteoporosis
Osteoporosis is characterised by low bone mass and microarchitectural deterioration of bone tissue leading to enhanced
bone fragility and a consequent increase in fracture risk.
Osteoporosis and fracture risk increase exponentially in
postmenopausal women. Osteoporosis is under-diagnosed and
under-treated and advancing age is a risk factor for undermanagement. Osteoporosis management in older people (75
years and over) must focus on non-pharmacological and
pharmacological interventions. The aim of treatment is to reduce
morbidity and mortality associated with the first fracture and
prevent subsequent fractures. Successful non-pharmacological
measures include falls risk assessment and management,
participation in exercise programs and the use of hip protectors.
Pharmacotherapies such as calcium, vitamin D, alendronate,
risedronate, zoledronic acid, teriparatide and strontium ranelate
are safe in older people and significantly reduce fractures,
especially vertebral fractures. There is less evidence for risk
reduction in non-vertebral and hip fractures, which are more
relevant in older people. The body of evidence in this cohort is
small and further studies are needed to provide more evidence.
J Pharm Pract Res 2010; 40: 229-34.
Intrinsic factors
Extrinsic factors
Genetic
Nutrition and lifestyle
-family history of fragility
fracture
-inadequate dietary calcium
intake
INTRODUCTION
Osteoporosis is characterised by the loss of bone mass
or the presence of a fragility fracture. 1 Osteoporosis
pathogenesis centres on an imbalance between
osteoclastic (bone breakdown) and osteoblastic (bone
formation) activity. Besides age, a number of other risk
factors for osteoporosis have been identified (Table 1).
Fragility fractures are associated with significant
disability, mortality and costs.2 People with previous
fractures have a higher risk of sustaining subsequent
fractures than the non-fracture population.2 Available
therapies can reduce the risk of recurrent fractures by 30
to 60% within a year of starting treatment.1
Osteoporosis prevalence is increasing because of
increased life expectancy and an ageing population.2
Although older people (75 years and over) bear the
greatest burden of fracture risk they are underrepresented in clinical trials and are less likely to be
managed appropriately than their younger counterparts,
highlighting that osteoporosis management in older
people represents therapeutic challenges for clinicians.2
Charles A Inderjeeth, MBChB, FRACP, MPH, Consultant Geriatrician, and
Rheumatologist, North Metropolitan Area Health Service, and Clinical
Professor, University of Western Australia, Sir Charles Gairdner Hospital, Kate
E Poland, MBBS, Junior Medical Officer, North Metropolitan Area Health
Service, Sir Charles Gairdner Hospital, Nedlands, Western Australia
Address for correspondence: Clinical Professor Charles Inderjeeth, Area
Rehabilitation and Aged Care, Sir Charles Gairdner Hospital, Nedlands WA
6009, Australia.
E-mail: Charles.Inderjeeth@health.wa.gov.au
Hormonal and reproductive
-vitamin D deficiency
-low body weight
-hyperthyroidism
-hyperparathyroidism
-short duration of reproductive
life (females)
-low testosterone level (males)
-excessive alcohol intake
-smoking
-physical inactivity
Medications
-corticosteroids
-selective serotonin reuptake
inhibitors
-androgen deprivation therapy
Comorbidities
-anticonvulsants
-rheumatoid arthritis,
inflammatory and chronic
diseases
-diuretics
-malabsorption with intestinal
disease
OLDER PEOPLE
In Australia, of the 75 000 fragility fractures that occur
annually, approximately 21 000 are hip fractures.3 The
average cost of hospitalisation post hip fracture is
$23 000.3 Twelve months after a hip fracture, 20% of
patients die, 50% experience permanent disability and
25% require permanent nursing home care.3 In 2001, the
direct costs attributable to osteoporotic fractures were
estimated at $1.9 billion.4
Worldwide epidemiological data have demonstrated
that the annual incidence of fragility fracture increases
with age. 5 Above average fracture rates have been
described in women with an exponential increase in risk
in women over 74 years. 6,7 The fracture burden is
expected to increase with an ageing population. Women
80 years and over comprise 8% of the postmenopausal
population but contribute to over 30% of fragility fractures
and 60% of hip fractures because of the high prevalence
of osteoporosis and falls in this age group.8 In people
over 75 years, hip fracture is the most prevalent fracture
with one-third of women and one-sixth of men sustaining
a hip fracture by the ninth decade.2,3,9
DIAGNOSIS
Although fragility fracture is the hallmark of
osteoporosis, diagnosis centres on assessment of bone
mineral density with dual energy X-ray absorptiometry.1
For women, the World Health Organization and
International Osteoporosis Foundation have identified
four diagnostic categories for dual energy X-ray
Journal of Pharmacy Practice and Research Volume 40, No. 3, 2010.
229
absorptiometry guiding treatment based on bone mineral
density with or without fractures (Table 2).10,11 When
bone mineral density is not feasible, two web-based tools
may be useful for assessing osteoporosis risk and
threshold for treatment (WHO Fracture Risk Assessment
Tool <www.sheffield. ac.uk/FRAX> and the Garvan
Institute’s Fracture Risk Calculator <garvan.org.au/
promotions/bone-fracture-risk/calculator/>).
Table 2. WHO and the International Osteoporosis Foundation
DEXA assessment diagnostic categories
Category
Hip bone mineral density
Normal
T-score > -1
Low bone mass (osteopenia)
T-score < -1 and > -2.5
Osteoporosis
T-score < -2.5
Severe osteoporosis
(established osteoporosis)
T-score < -2.5 and presence of
at least one fragility fracture
DEXA = dual energy X-ray absorptiometry.
T-score = number of standard deviations below the mean value of
the young healthy population.
NON-PHARMACOLOGICAL MANAGEMENT
The non-pharmacological approach to managing
osteoporosis centres on fracture prevention strategies.
Falls Risk Assessment and Prevention
Around 30% of people 65 years and over and living in
the community and over 50% living in residential care
facilities fall each year.12 Older people are at a higher risk
of trauma due to falls and over 90% of fractures occur
after a fall.13 Falls result in any type of fracture in 5% and
hip fracture in 1 to 2% of events.14 Therefore, reducing
falls risk is important in an ageing osteoporotic
population. Most falls are associated with identifiable
risk factors, e.g. unsteady gait, visual impairment,
medications, and addressing these factors can
significantly reduce falls.15 A large body of evidence
supports falls prevention programs, such as medication
review, multidisciplinary risk factor assessment,
modification of the environment and participation in
exercise programs, are the optimal approach to preventing
falls in older people.15
Exercise Programs
Risk factors, such as muscle weakness and impaired
balance can be modified by exercise. Strength and
balance training for the elderly living in the community
can reduce the risk of falls by 15 to 50%.16 Balance training
is the most effective exercise in reducing falls risk.16
Hip Protectors
Hip protectors redirect the force and energy of a fall away
from the hip and reduce the chance of hip fracture.
Although studies have reported variable outcomes with
hip protectors, evidence supports their use as beneficial
when compliance is adequate.17,18
PHARMACOLOGICAL MANAGEMENT
The groups that benefit most from pharmacotherapy are
women with osteoporosis confirmed on bone mineral
density (with or without fractures) and osteopenic women
who have sustained fractures. 4 As there is limited
evidence for older men the focus of this review is on
women only. Pharmacotherapies commonly used include:
calcium, vitamin D, bisphosphonates, strontium ranelate,
teriparatide, raloxifene and denosumab (Table 3).
230
Calcium and Vitamin D
Calcium deficiency is associated with accelerated bone
resorption in the postmenopausal period as there is a
decline in intestinal calcium absorption and increased
urinary calcium excretion.19 Calcium supplementation has
been demonstrated to reduce fracture risk. 20 The
recommended daily intake of calcium in women over 50
years and men over 70 years is 1300 mg.19 Calcium
supplementation is recommended if dietary intake is
suboptimal. 18 Calcium supplementation beyond the
recommended daily intake may be associated with
increased cardiovascular events.21
Adequate vitamin D status is essential for calcium
metabolism. With increasing age, vitamin D levels decline,
resulting in malabsorption of calcium and increased
secretion of parathyroid hormone, leading to accelerated
bone loss.4,22 Vitamin D deficiency is also an independent
predictor of falls and fragility fractures.22-24 Although the
optimal level of serum 25-hydroxy vitamin D is unknown,
values from 50 to 100 nmol/L have been suggested as
optimal.24 The at-risk population, i.e. those in institutional
care and those with known osteoporosis, should aim for
a minimum serum 25-hydroxy vitamin D level of over 50
nmol/L and an optimal level of over 75 nmol/L.24 A daily
intake of vitamin D 800 IU achieves serum 25-hydroxy
vitamin D levels over 50 nmol/L and does not need
monitoring.18,25 High-dose intermittent vitamin D may
correct deficiency sooner and achieve better
compliance. 26 Sanders et al. 27 have suggested an
increased risk of falls and fractures in older community
dwelling women within three months of administrating
annual oral high-dose cholecalciferol. This risk has not
been identified in other similar studies. Until more data
are available, the benefit of high-dose vitamin D needs to
be balanced against the risks.
Calcium and vitamin D in combination are more
beneficial in reducing fracture rates than either treatment
alone.28 This combination has minimal adverse effects
but compliance remains a limitation. Combined calcium
and vitamin D should be used in all patients diagnosed
with osteoporosis unless other non-pharmacological
measures are deemed adequate. Although concerns have
been raised for the increased risk of cardiovascular events
with excessive doses of calcium, there is no suggestion
of any increase in risk with calcium and vitamin D in
combination with or without antiresorptive drugs in
patients with osteoporosis.21,28-43
Bisphosphonates
The most commonly used medications for fracture
prevention are the bisphosphonates. Alendronate,
clodronate and risedronate are taken orally in a fasting
state due to low bioavailability and with precautions to
avoid gastrointestinal adverse effects. The intravenous
bisphosphonate, zoledronic acid, has been approved for
treatment of osteoporosis and has the advantage of onceyearly dosing and a reduction in gastrointestinal adverse
effects.
Alendronate
Ensrud et al.29 undertook a subgroup analysis of patients
75 years and over from the Fracture Intervention Trial to
investigate whether treatment with alendronate prevents
fractures in women at highest risk.30 Although the initial
intention–to–treat study demonstrated benefit for
vertebral and non-vertebral fractures, the older subgroup
Journal of Pharmacy Practice and Research Volume 40, No. 3, 2010.
Table 3. Osteoporosis treatments and evidence of fracture risk reduction efficacy in women 75 years and over
Fracture risk reduction
Drug
Route/frequency
VF
N VF
HF
Calcium and vitamin D Variable*
+
+
+
Alendronate
Oral/weekly
+
N/A
N/A
Risedronate
Oral/weekly
+
-
-
Studies with a significant number of women 75 years and over
Boonen et al.32 (79-79 years: NVF risk HR 0.8; 95%CI 0.7-0.97;
p = 0.03); (80+ years: non-significant; p = 0.7)
McClung et al.35 (HF risk) (years intention-to-treat: HR 0.7;
95%CI 0.6-0.9; p = 0.02); (70-79 years: HR 0.6; 95%CI 0.4-0.9;
p = 0.01); (80+ years: non-significant; p = 0.4)
Masud et al.36 high-risk subgroup (70-100 years: HF risk HR 0.5;
95%CI 0.3-0.9; p = 0.02); (75+ years: not reported)
Clodronate
Oral/daily
Zoledronic acid
Intravenous/yearly
N/A
N/A
-
+
+
-
Boonen et al.38 (HF risk) (75+ years: non-significant; p > 0.05);
(< 75 years: p < 0.001; treatment-by-age interaction: p = 0.04)
Black et al.39 (mean 73 ± 5.4 years: HF risk HR 0.6; 95%CI 0.40.8; p < 0.001)
Lyles et al.40 (50+ years: HF risk HR 0.7; 95%CI 0.4-1.2; p = 0.5)
Strontium ranelate
Oral/daily
+
+
+
Teriparatide
Subcutaneous/daily
+
-
N/A
Denosumab
Subcutaneous/
6-monthly
N/A
N/A
N/A
Cummings et al.48 (60-90 years: VF risk HR 0.3; 95%CI 0.3-0.4;
p < 0.001; NVF risk HR 0.8; 95%CI 0.7-0.95; p = 0.01; HF risk
HR 0.6; 95%CI 0.4-0.97; p = 0.04)
*Oral/IM and variable dosing. + = fracture risk reduction demonstrated. - = fracture risk reduction not demonstrated.
VF = vertebral fracture. NVF = non-vertebral fracture. HF = hip fracture. HR = hazard ratio. RR = relative risk. N/A = data unavailable.
only reported evidence for vertebral fracture relative risk
reduction at three years (RRR 38%; p < 0.05). 29 No
published data are available for non-vertebral or hip
fracture in the older population. Greenspan et al. 31
reported an increase in spine and hip bone mineral density
in older women receiving alendronate but there were no
fracture endpoints. There are no published studies on
adverse outcomes in the older age group for alendronate.
Risedronate
Boonen et al. 32 pooled and analysed data from three
randomised, placebo-controlled, parallel group trials to
investigate the safety and efficacy of risedronate in
reducing fracture risk in osteoporotic women 80 years
and over.33-35 The Vertebral Efficacy with Risedronate
Therapy studies determined the effect of risedronate on
vertebral fractures in women with postmenopausal
osteoporosis and the hip intervention program (HIP)
study evaluated the effect of risedronate on hip fractures
in elderly women (70 to 79 years) with osteoporosis or
risk factors (80+ years).33-35
Boonen et al.32 demonstrated evidence for significant
vertebral fracture relative risk reduction at one year (RRR
81%; p < 0.001) and three years (RRR 44%; p = 0.003). No
benefit in non-vertebral fracture risk was reported in the
older cohort (p = 0.7) but the younger cohort (mean age
72 years; range 41 to 79) showed benefit (HR 0.8; 95%CI
0.7–0.97; p = 0.03). Hip fracture outcomes were not
reported in the pooled analysis.32 There was no significant
treatment–by–age group interaction for vertebral fracture
(p = 0.7) but treatment effect for non-vertebral fracture
was significant for patients under 80 years but not in
patients 80 years and over.
In the intention–to–treat group of the HIP study (70
to 100 years), risedronate demonstrated a lower relative
risk of hip fracture (RR 0.7; 95%CI 0.6–0.9; p = 0.02).35 In
the 70 to 79 years subgroup selected on the basis of
osteoporosis, the risk reduction was significant (RR 0.6;
95%CI 0.4–0.9; p = 0.009). Benefit was not demonstrated
in the older cohort (80+ years; p = 0.4), who were selected
predominantly on the basis of non-skeletal risk factors
(58% of patients).35
A further post hoc analysis of patients from the HIP
study (70 to 100 years; mean 77 ± 5) who met the WHO
and the International Osteoporosis Foundation criteria
for severe osteoporosis (T score < –2.5 and one or more
prior vertebral fracture) demonstrated the efficacy of
risedronate in reducing hip fracture risk at three years
(RR 0.5; 95%CI 0.3–0.9; p = 0.02).36 Subgroup analyses
for the older cohort were not presented separately.
Clodronate
Clodronate did not demonstrate any significant benefit
in hip fracture risk reduction in a study that randomised
community-dwelling women over 75 years who did not
have proven osteoporosis or any other risk factors.37
Zoledronic Acid
Boonen et al.38 conducted a post hoc subgroup analysis
of pooled data from the multicentre, randomised, doubleblind, placebo-controlled HORIZON Pivotal Fracture Trial
and HORIZON Recurrent Fracture Trial.39,40 The Pivotal
Fracture Trial enrolled women with a bone mineral
density T-score < –2.5 or T-score < –1.5 with radiological
evidence of at least one vertebral fracture (mean age 73 ±
5.3 years; 38% ≥ 75 years).39 This trial reported a 70%
reduction in vertebral fracture, 25% in non-vertebral
fracture and 41% in hip fracture (p < 0.01 for all values).39
Journal of Pharmacy Practice and Research Volume 40, No. 3, 2010.
231
The Recurrent Fracture Trial enrolled patients post hip
fracture (mean age 74 ± 9.5 years; 55% ≥ 75 years) and
the main outcomes reported in this mixed age cohort were
a reduction in new clinical fracture (35%; p = 0.001), new
clinical vertebral fracture (p = 0.002), non-vertebral fracture
(p = 0.03) but not hip fracture (p = 0.5).40 They also reported
an overall mortality benefit (RR 0.7; 95%CI 0.6–0.9; p =
0.01).40
Boonen et al.38 examined postmenopausal women 75
years and over with documented osteoporosis or a recent
hip fracture. At three years the incidence of vertebral
(HR 0.3; 95%CI 0.2–0.6; p < 0.001) and non-vertebral
fractures (HR 0.7; 95%CI 0.6–0.9; p = 0.02) were
significantly lower in the zoledronic acid group. 38
Although patients younger than 75 years significantly
benefited in hip fracture risk reduction at three years (p <
0.001), this was not observed in the older subgroup and
the treatment–by–age interaction was statistically
significant between the two groups (p = 0.04). Although
the adverse effect profile in the older cohort was similar
to the younger cohort, fewer patients over 75 years
reported adverse events from active treatment compared
with those under 75 years, except for renal impairment.
Strontium Ranelate
Seeman et al.41 investigated whether strontium ranelate
can reduce the risk of vertebral and non-vertebral
fractures in older women (80+ years) by pooling data
from two phase III, randomised, placebo-controlled,
double-blind studies.42,43 They reported evidence for
significant vertebral fracture relative risk reduction at one
year (RRR 59%; p = 0.002) and three years (RRR 32%; p =
0.01).41 There was also evidence for significant nonvertebral fracture relative risk reduction at one year (RRR
41%; p = 0.03) and three years (RRR 31%; p = 0.01). The
analysis demonstrated non-significant reduction in hip
fractures at three years (32%; p = 0.1).41 Reginster et al.43
reported a 36% reduction in hip fracture at three years in
osteoporotic women 74 years and over but not in the
total cohort (70 years and over). Strontium ranelate did
not result in more adverse events than placebo.41
Teriparatide
Teriparatide stimulates bone turnover, with a positive
bone balance resulting in increased bone mass. 44
Teriparatide is funded by the Pharmaceutical Benefits
Scheme as an alternative treatment in patients who have
a very high risk of fracture (bone mineral density T-score
< –3), have experienced two or more fragility fractures
and at least one symptomatic new fracture after 12 months
of continuous therapy with an antiresorptive drug or are
intolerant of antiresorptive drugs.
The teriparatide subgroup study, analysed the
Fracture Prevention Trial to determine whether older
women (75+ years) had similar safety and efficacy to
younger women.45,46 The analysis compared whether there
was a significant interaction between treatment
(teriparatide 20 mg vs placebo) and age (< 75 years vs >
75 years). They reported no age–treatment interaction (p
= 0.4), significant vertebral fracture relative risk reduction
at one year (RRR 65%; p < 0.05) but no evidence for
significant non-vertebral fracture relative risk reduction
at one year. There was no increase in treatment-emergent
adverse events compared to placebo in those over 75
years compared to the intention–to–treat cohort and
younger groups.
232
Raloxifene
Raloxifene has been used in early postmenopausal women
with demonstrated reduction of vertebral fractures but
not non-vertebral or hip fractures. 47 Although older
women have been included in some studies, the numbers
are small and there are no published data in older cohorts
or subgroups.
Denosumab
Denosumab, a new fully human monoclonal antibody
targets and binds with high affinity and specificity to
RANK ligand and prevents activation of RANK receptors
found on osteoclast precursors and osteoclasts.
Denosumab inhibits the development and activity of
osteoclasts, decreases bone resorption and increases
bone density. A study of 7868 women (60 to 90 years;
mean 72 + 5.2) included 32% of women 75 years and over
with bone mineral density confirmed osteoporosis with
or without prevalent fractures.48 In the mixed age cohort,
vertebral fractures were reduced by 61% at one year and
68% by three years (p < 0.001 for both). Non-vertebral
fractures were reduced by 20% (HR 0.8; 95%CI 0.7–0.95;
p = 0.01) and hip fractures were reduced by 40% (HR 0.6;
95%CI 0.4–0.97; p = 0.04) by three years.
DISCUSSION
Despite the high risk of osteoporotic fractures in older
people, there is little published evidence on treatment in
this cohort. Studies have either included limited numbers
or excluded older people due to strict entry criteria based
on age and related factors. There is favourable published
safety data for risedronate, zoledronic acid, strontium
ranelate and teriparatide use in older people.
Fracture Risk Reduction
There is acceptable evidence to recommend alendronate,
risedronate, zoledronic acid, strontium ranelate and
teriparatide for vertebral risk fracture risk reduction in
older people. There is significant early onset of benefit
(within 12 months) with risedronate, zoledronic acid,
strontium ranelate and teriparatide. At three years, there
is evidence for sustained benefit with alendronate,
risedronate, zoledronic acid and strontium ranelate.
Published data on non-vertebral fractures are limited.
There is evidence of benefit from zoledronic acid and
strontium ranelate. Strontium ranelate demonstrated nonvertebral fracture risk reduction at one year and a
sustained benefit at three years. Zoledronic acid
demonstrated benefit at three years only.
Evidence for hip fracture risk reduction is also limited.
Strontium ranelate was the only drug to demonstrate hip
fracture reduction in older patients with confirmed
osteoporosis.43 In the zoledronic acid study, although
patients under 75 years showed a significant hip fracture
risk reduction, it did not translate into statistically
significant benefits for those over 75 years.38 However,
this study was limited by its power to demonstrate a
benefit. The trials that evaluated risedronate and
clodronate in older patients with hip fractures
demonstrated no benefit. 35,37 However, these studies
targeted old, frail patients with risk factors rather than
established osteoporosis. This is at odds with the
demonstrated benefit in the HIP cohort (under 80 years)
and the intention–to–treat cohort (70 to 100 years).35,36
Journal of Pharmacy Practice and Research Volume 40, No. 3, 2010.
Most treatments showing efficacy in fracture
reduction in older people have been over three years.
However, strontium ranelate was beneficial in the
reduction of all major fractures (including hip and nonvertebral) for up to five years in old, frail and osteoporotic
women.49,50 Based on the available evidence in this older
age group, strontium ranelate would be a suitable firstline option if reduction in vertebral, non-vertebral and
hip fractures is the goal. This is notwithstanding other
considerations such as dosing, frequency, adherence,
tolerability, and patient and clinician preferences.51
Senile Osteoporosis
Discrepancies in non-vertebral and hip fracture reduction
between young and old people may reflect differences
in skeletal and non-skeletal risk factors. 52,53 Senile
osteoporosis may need to be distinguished from other
types of osteoporosis.52 Hip fracture is the predominant
fracture after the seventh decade of life and hip strength
relies on preservation of osteoblastic activity (often
impaired by ageing). By contrast, postmenopausal
osteoporotic fractures occur due to increasing
osteoclastic activity and decline in osteoblastic activity
in the older population. Young postmenopausal women
predominantly have high bone turnover osteoporosis
and older women may have senile osteoporosis.
Reducing bone remodelling without improving bone
formation may be inadequate in older people who mostly
sustain non-vertebral and hip fractures. This may be
supported by the observation that there may be an age
interaction with treatment benefit in some
bisphosphonate studies and why strontium ranelate and
teriparatide with their osteoblastic-activity promoting
properties show more promise in this age group.
Interventions
Given the positive impact of osteoporosis medications
on fracture prevention, low risk of drug–drug interactions
and low incidence of adverse effects, they should not be
considered ‘inappropriate prescriptions’ in older patients.
There is a significant relationship between increasing
age and decreasing likelihood of receiving effective
osteoporosis treatment. 54 Selection of an appropriate
medication includes consideration of dose, frequency,
route of administration, adverse effects, adherence, costeffectiveness and ability to prevent fractures early.
Improving medication persistence irrespective of the
drug is an important goal to ensure efficacy.51,55
The most cost-effective use of resources is to
intervene in patients with pre-existing fractures.3 As older
people are at a higher risk of fracture, they are likely to
derive greater benefit from osteoporosis treatment than
younger people. 29 The cost benefit ratios are more
favourable given the high absolute risk in older patients.56
Ironically, the least evidence is available for fracture
reduction in the group at greatest risk. Older people have
unique needs and differ from younger people in terms of
their fragility fracture risk. Fracture is a consequence of
a triad of factors: bone quality, precipitating event and
the interface between the bone and contact surface. 2
Improving calcium and vitamin D status and the use of
non-pharmacological measures including hip protectors
are important adjunctive strategies. Older patients derive
greatest benefit from a multifactorial and multidisciplinary
approach.
CONCLUSION
Osteoporosis will continue to be a major public health
issue as the population ages. Non-pharmacological and
pharmacological measures have roles to play in
osteoporosis management. The evidence highlights that
a number of drugs can safely reduce osteoporosis risk in
older patients and appropriate management will reduce
the morbidity, mortality and economic costs associated
with this disease. However, there is a need for further
randomised controlled trials to provide more evidence
for treatment in older people.
Competing interests: None declared
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Received: 26 May 2010
Revisions requested after external review: 2 August 2010
Revised version received: 16 August 2010
Accepted: 30 August 2010
Journal of Pharmacy Practice and Research Volume 40, No. 3, 2010.