There are several levels at which research into osteoporosis should be carried out in Australia, with a focus on groups that have expertise in the areas of osteoporosis, bone biology, epidemiology, rehabilitation or large scale trials. Much of the basic research can and should be supported through expansion of existing peer reviewed funding. However, there is room for targeted interactions between basic scientific research and industry.

Research issues identified as being crucial to better and more cost-effective prevention and treatment of osteoporosis include:

Defining the magnitude of the problem

• Better understanding of the epidemiology of osteoporosis in general and in various ethnic groups in particular.

• Better understanding of costs, morbidity and mortality in non-hip fractures.

Pathophysiology

• Basic bone biology, including identification of effective bone anabolic agents and understanding of genetic mechanisms.

Detection

• More efficient and cost-effective identification of individuals at high risk before fracture.

• New methods to measure bone fragility, to supplement or replace the measurement of density.

• Analysis of the role of genetic markers in diagnosis and selection of therapy.

A major focus in clinical application is the targeting of interventions to those at greatest risk and those most likely to respond to particular therapies. The roles of ultrasound, bone turnover markers, genetic factors and other clinical and biochemical indices need to be evaluated, to assess whether they assist in the selection of optimal therapy and could improve cost-effectiveness.

Prevention

• Clarification of factors in attainment of peak bone mass, including genetic and lifestyle factors.

• Clarification of the role and costs of lifestyle changes in preventing bone loss.

• Identification of the components of fall prevention programs which contribute most to reducing falls and fractures.

The role of genetics and lifestyle factors in attainment of peak bone mass, including their action in prepubertal children, needs to be addressed. The relative effects of genetics and lifestyle factors may vary at different points during life. Some studies indicate that the effects of exercise or calcium are greater before than during adolescence. However, these studies have not followed children through to adulthood to determine whether peak bone mass is actually altered. Clarification of these points would allow recommendations about whether osteoporosis-related health promotion activities should be directed towards children or adolescents. Evaluation should be built in to all such health promotion programs. Community-based intervention studies are needed to determine the uptake of messages about lifestyle changes and whether these lead to changes in important indicators of osteoporosis in the population.

Treatment

• Large scale comparative studies, including studies of combination therapies.

• Investigation of whether targeting therapies to those most likely to benefit from them is useful.

• Better understanding of optimal treatment (and prevention) of osteoporosis in men.

There is also a clear need for direct testing of possible drug combinations, when positive or negative interaction cannot be predicted reliably from current data. These should be in large scale, long-term controlled studies. There is room for partnerships between clinical science, pharmaceutical companies and government health bodies for the exploration of comparative drug studies, with appropriate evaluation of non-drug interventions as well. Identification of those most likely to benefit from any pharmaceutical or lifestyle intervention is a critical issue.

It is vital that the Australian community, including the public, health professionals, public health authorities and governments, recognise the scope and magnitude of the osteoporosis problem, both in human and economic terms. With this recognition, research can be targeted towards the prevention and optimal management of osteoporosis and associated fractures.

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