A Crisis in the Treatment of Osteoporosis - 10 Years Later, the US Care Gap is Still Open

A decade ago, we published an editorial in the Journal of Bone and Mineral Research describing a crisis in osteoporosis treatment. In this Perspective, we reassess osteoporosis care and progress addressing that crisis. Despite the availability of safe and effective medications that reduce fracture risk, the osteoporosis care gap persists and may have widened in the United States (US). Fewer than 15% of patients receive osteoporosis therapy within one year of a fragility fracture, and treatment rates declined between 2015 and 2022. Meanwhile, declining hip fracture rates plateaued around 2012 and remain stable, while clinical vertebral fractures have increased. Persistent barriers include limited patient awareness of bone health, low screening rates, reduced access to dual-energy X-ray absorptiometry (DXA), concerns regarding treatment-related adverse events, underutilization of fracture liaison services, as well as racial, ethnic, and socioeconomic disparities. Despite this, the tools available to address the crisis have expanded. Advances that can help narrow the current care gap include new osteoanabolic agents; improved understanding of atypical femur fracture risk-benefit profiles; goal-directed treatment; opportunistic screening and diagnosis; artificial intelligence-enabled vertebral fracture detection; and electronic medical record-based decision support. Other developments may reduce the future burden of osteoporosis and fracture, including growing evidence supporting primary prevention, evolving perspectives on menopausal hormone therapy, and U.S. Food and Drug Administration qualification of total hip bone mineral density as a surrogate endpoint for fractures, which may facilitate more efficient drug development. The challenge now is to implement available approaches for patients at high fracture risk while continuing to consider strategies that shift osteoporosis care toward earlier prevention. Progress will require coordinated action by healthcare systems, providers, payers, professional societies, and policymakers to improve equitable access to fracture prevention.