Osteoporosis management in Europe is guided by comprehensive, multi-layered strategies that combine pharmacological treatments with essential lifestyle modifications. While overall objectives are consistent, specific national guidelines and reimbursement policies can influence the initial approach and choice of therapy. The goal is to reduce fracture risk and improve patient quality of life, using a range of therapies tailored to the individual's risk profile.
The European Approach to Diagnosis and Risk Assessment
Before initiating treatment, a thorough assessment is crucial. The diagnostic definition of osteoporosis typically relies on a T-score of -2.5 or lower, measured using dual-energy X-ray absorptiometry (DXA). However, guidelines across Europe employ different risk assessment methods:
- Risk Assessment Tools: In countries like the UK, Germany, and Italy, national guidelines recommend using validated risk tools, such as the FRAX® algorithm, which calculates the 10-year probability of a major osteoporotic fracture.
- Prior Fractures: In other regions, including France and Spain, the presence of prior fractures, particularly at the spine or hip, is a key factor in triggering treatment consideration.
- DXA Scans: DXA scans of the femoral neck and lumbar spine are standard practice. Additional metrics like the Trabecular Bone Score (TBS) can provide supplementary information on bone quality.
The Importance of Sequential and Long-Term Treatment
Managing osteoporosis is a long-term process, often requiring a sequence of different medications to maintain efficacy and safety. For example, in patients at very high risk, anabolic agents may be used first to rebuild bone, followed by antiresorptive drugs to preserve bone mass. The decision to stop treatment is made on an individual basis, usually after 3-5 years for bisphosphonates, but is not advisable for agents like denosumab without a planned transition to another therapy.
Pharmacological Treatment Options in Europe
European treatment regimens utilize several classes of drugs, with the specific choice depending on factors such as fracture risk, potential side effects, and patient preference.
Antiresorptive Therapies (Reduce Bone Breakdown)
- Bisphosphonates: Oral bisphosphonates, including alendronate and risedronate, are a common first-line treatment, especially for high-risk patients, due to their proven efficacy and cost-effectiveness. Intravenous bisphosphonates like zoledronic acid are alternatives for those intolerant to oral options or for post-hip fracture patients. Treatment duration is typically reviewed after 3-5 years.
- Denosumab: This monoclonal antibody is administered via subcutaneous injection every six months and is an option for patients at high fracture risk, particularly if bisphosphonates are not suitable. Discontinuation of denosumab requires transitioning to another antiresorptive therapy to prevent a rapid increase in fracture risk.
- Selective Estrogen Receptor Modulators (SERMs): Raloxifene is approved for postmenopausal osteoporosis. It acts on the estrogen receptor to reduce vertebral fracture risk but does not typically reduce the risk of non-vertebral fractures.
Anabolic Therapies (Stimulate Bone Formation)
- Teriparatide: A synthetic form of parathyroid hormone, teriparatide is recommended for patients at very high fracture risk. It is typically followed by an antiresorptive agent to maintain the bone mineral density gains.
- Romosozumab: A dual-action drug approved for postmenopausal women with severe osteoporosis, romosozumab increases bone formation and decreases bone resorption.
- Abaloparatide: Approved in Europe for postmenopausal women at increased fracture risk, this anabolic agent is a synthetic peptide analogue of parathyroid hormone-related protein.
Non-Pharmacological Interventions and Lifestyle Management
Lifestyle measures form the cornerstone of osteoporosis management, complementing drug therapy to optimize bone health.
- Diet and Nutrition: Adequate intake of calcium (800-1200 mg/day) and vitamin D (800 IU/day) is essential. This can be achieved through diet, such as dairy products and leafy greens, or through supplements, especially for those with insufficient levels.
- Exercise: Regular, weight-bearing, and muscle-strengthening exercises are crucial for maintaining bone density and improving balance. This can include brisk walking, aerobics, or weightlifting, with programs tailored to individual abilities.
- Fall Prevention: Identifying and mitigating fall risks is critical to preventing fractures. This includes improving home environments, assessing gait, and reviewing medications that may affect balance.
- Risk Factor Modification: Limiting alcohol consumption and quitting smoking are also important preventative strategies.
Comparison of Major Osteoporosis Treatments
| Feature | Bisphosphonates | Denosumab | Anabolic Agents (Teriparatide, Romosozumab) |
|---|---|---|---|
| Mechanism | Inhibits bone resorption (osteoclast activity) | Blocks RANKL to reduce osteoclast formation and activity | Stimulates new bone formation |
| Administration | Oral tablets (daily/weekly/monthly) or intravenous injection (annually) | Subcutaneous injection every 6 months | Daily subcutaneous injection (Teriparatide) or monthly for 12 months (Romosozumab) |
| Primary Use | First-line treatment for high fracture risk | Alternative for patients intolerant to bisphosphonates or as a second-line therapy | Very high fracture risk or severe osteoporosis; often followed by antiresorptive therapy |
| Key Considerations | Long-term use reviewed after 3-5 years; requires careful consideration of potential side effects | Rebound fracture risk upon discontinuation necessitates follow-up antiresorptive therapy | Treatment duration is limited, and sequential therapy is required |
Conclusion: A Multi-Pronged Strategy
How is osteoporosis treated in Europe involves a sophisticated, multi-pronged approach that combines targeted medication with fundamental lifestyle changes. European guidelines emphasize tailoring treatment to the individual's specific fracture risk, with oral bisphosphonates serving as a common starting point. For those at very high risk, anabolic agents may be used first, followed by an antiresorptive drug. However, a significant gap exists between those needing treatment and those receiving it, highlighting a continued need for improved identification and management. With an aging population, proactive diagnosis and the strategic application of both pharmaceutical and non-pharmaceutical interventions will be crucial in reducing the substantial personal and economic burden of fragility fractures in Europe. For more information, please consult the International Osteoporosis Foundation (IOF) at osteoporosis.foundation.
