Controversies in osteoporosis – are we treating bone density or preventing fractures?

Osteoporosis is a significant public health issue associated with increased fracture risk, particularly in the aging population. Earlier strategies for fracture prevention were largely based on the assumption that fractures are primarily caused by low bone mineral density (BMD) fulfilling the World Health Organization (WHO) densitometric criteria for osteoporosis, and that pharmacological treatment aimed at increasing BMD would consequently reduce fracture risk. This approach shifts the focus from overall fracture risk to BMD alone, overlooking other key determinants of bone strength and resistance. Therefore, fracture risk assessment requires a comprehensive approach that incorporates not only BMD but also bone quality, the FRAX tool, trabecular bone score (TBS), fall risk, and a history of prior fractures. Fracture prevention should not rely solely on pharmacotherapy, but also include nutritional optimization, adequate intake of calcium, vitamin D, and protein, as well as regular physical activity and fall prevention strategies. Antiresorptive agents (bisphosphonates, denosumab) and anabolic drugs (teriparatide) are effective but require periodic re-evaluation due to potential long-term adverse effects. The concept of deprescribing, particularly in frail or immobile older adults, emphasizes rational, individualized treatment decisions. The goal of osteoporosis management is not merely to increase BMD but to reduce overall fracture risk through an integrated approach combining risk assessment, fall prevention, and tailored pharmacologic therapy.