The management of osteoporosis has undergone a significant shift in recent years, driven by strategies focused on early detection and fracture risk reduction. New strategies allow clinicians to anticipate osteoporosis and reduce its impact. This is particularly relevant given improved identification of risk factors — especially the presence of prior fragility fractures.
What It Is and Why It Matters
Osteoporosis is a systemic bone disease characterized by low bone mineral density and deterioration of bone microarchitecture, resulting in reduced bone strength and greater susceptibility to fractures. The disease has its greatest impact in vertebral and hip fractures — among the most frequent and clinically significant, associated with disability, morbidity, and increased mortality.
In Spain, roughly 3 million people suffer from osteoporosis, with greater prevalence in women, according to Dr. Montserrat Robustillo, a rheumatologist at the University Hospital of La Plana in Castellón. She notes that fragility fractures account for approximately 300,000 cases per year — roughly one every two minutes — with an estimated annual healthcare cost of around 4.3 billion euros, or approximately 3.8% of healthcare spending.
Aging, Lifestyle, and Fracture Risk
The relationship between disease prevalence and population aging is direct. According to the latest INE data, individuals over 64 already represent nearly 20% of the Spanish population. Fracture risk depends not only on bone mineral density, but also on age, prior bone fractures, falls, sarcopenia, and other clinical conditions. Given current demographic trends, fragility fractures could increase by around 30% over the next decade. Contributing factors include sedentary behavior, low-impact physical activity, smoking, excessive alcohol consumption, low calcium and vitamin D intake, and increased fall risk.
Better Understanding, Better Management
Although traditionally associated with patients over 65, osteoporosis is increasingly being addressed at an earlier stage. Current clinical guidelines have professionals combining clinical factors with tools such as bone densitometry to identify risk early. A significant shift has taken place: ‘It is possible that we used to wait for a fracture to appear, but now we try to get ahead of it by paying attention to osteoporotic risk factors,’ says Dr. Robustillo.
The Prior Fracture: A New Key Risk Factor
‘A prior fracture not only informs us of the bone’s current state — it marks a before and after in the patient’s risk. After a first fragility fracture, the risk of a new fracture is not uniform over time; it is highest in the first two years, which can be described as a true cascade effect.’ Not acting during this higher-risk period would allow new fractures to accumulate, worsening the functional and vital prognosis.
Beyond Densitometry: Stratifying Risk
The current clinical approach goes beyond measuring bone mass — it estimates fracture risk comprehensively, integrating age, prior fragility fracture, family history of fracture, glucocorticoid use, and comorbidities such as inflammatory diseases, diabetes, chronic kidney disease, and early menopause. Tools such as the FRAX calculator have been fundamental precisely because they integrate these clinical factors, allowing calculation of 10-year fracture probability. This risk stratification allows patients to be classified by level of risk (moderate, high, or very high) so that therapeutic strategies can be tailored accordingly.
Outstanding Gaps and New Tools
Gaps remain in the identification of undiagnosed vertebral fractures (occurring in up to 80% of cases), fall risk, sarcopenia, and certain comorbidities. There is also an important gap in the initiation of treatment after a first fracture — precisely when it would have the greatest impact. In this context, organizational models such as Fracture Liaison Services (FLS) — which actively identify patients after their first fracture and evaluate their risk for immediate preventive action — are gaining importance.
Regarding AI, Dr. Robustillo notes that its role ‘is beginning to be very promising, especially in opportunistic screening on CT scans performed for other reasons, automatic detection of vertebral fractures that often go unnoticed, and prediction models that combine imaging, clinical data, and patient history as a complement to clinical assessment.’
Thinking Ahead
Bone health begins to be built well before menopause or old age. A large part of ‘bone capital’ is acquired during childhood and adolescence. ‘This has very clear preventive implications: the prevention of osteoporosis does not begin when the first fracture appears — it begins much earlier. The population-level strategy should include promoting exercise and nutrition from an early age, not only campaigns directed at older adults.’
Source: UNIVADIS.ES
