Underdiagnosis 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.