Underdiagnoses 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.