Vignettes in osteoporosis: a road map to successful therapeutics.
The diagnosis and management of osteoporosis have become increasingly more complex as new drugs enter the marketplace and meta-analyses of randomized trials with "other" agents become more prolific. We describe five common clinical scenarios encountered in the practice of osteoporosis medicine and various road maps that could lead to successful therapy.


BACKGROUND
The diagnosis and treatment of osteoporosis have changed dramatically in the last decade. Advances in diagnostic technologies and a range of newer treatment options have provided the clinician with a wide array of choices for treating this chronic disease. Despite the issuance of several "guidelines" and practice recommendations, there still remains confusion among clinicians about basic approaches to the management of osteoporosis. This paper should be used as a case-based approach to define optimal therapeutic choices.


METHODS
Five representative cases were selected from two very large clinical practices (Bangor, ME; Pittsburgh, PA). Diagnostic modalities and treatment options used in these cases were selected on an evidence-based analysis of respective clinical trials. Subsequent to narrative choices by two metabolic bone disease specialists (SG and CR), calculation of future fracture risk and selection of potential alternative therapeutic regimens were reviewed and critiqued by an epidemiologist (DB).


RESULTS
A narrative about each case and possible management choices for each of the five cases are presented with references to justify selection of the various therapeutic options. Alternatives are considered and discussed based on literature and references through July 2003. The disposition of the individual patient is noted at the end of each case.


CONCLUSIONS
A case-based approach to the management of osteoporosis provides a useful interface between guidelines, evidence-based meta-analyses, and clinical practice dilemmas.
Rosen
Clifford J
CJ
Maine Center for Osteoporosis Research and Education, St. Joseph Hospital, Bangor, Maine 04401, USA. rofe@aol.com
Black
Dennis M
DM
Greenspan
Susan L
SL
D000368:Aged; D000369:Aged, 80 and over; D015519:Bone Density; D001851:Bone Diseases, Metabolic / Q000517:prevention & control / Q000628:therapy; D002118:Calcium / Q000627:therapeutic use; D003424:Crohn Disease / Q000150:complications / Q000188:drug therapy; D004164:Diphosphonates / Q000627:therapeutic use; D004965:Estrogen Antagonists / Q000627:therapeutic use; D015914:Estrogen Replacement Therapy; D005260:Female; D005938:Glucocorticoids / Q000009:adverse effects / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D010024:Osteoporosis / Q000175:diagnosis* / Q000517:prevention & control / Q000628:therapy*; D015663:Osteoporosis, Postmenopausal / Q000175:diagnosis / Q000517:prevention & control / Q000628:therapy; D010281:Parathyroid Hormone / Q000627:therapeutic use; D014807:Vitamin D / Q000627:therapeutic use; D014808:Vitamin D Deficiency / Q000628:therapy
D004164:Diphosphonates; D004965:Estrogen Antagonists; D005938:Glucocorticoids; D010281:Parathyroid Hormone; D014807:Vitamin D; D002118:Calcium