To the Editor: We believe the current indications for subsidised treatment of osteoporosis specified in the Pharmaceutical Benefits Schedule (PBS) encourage over-prescribing on the one hand, yet, on the other, deny many patients with osteoporosis the treatment they need.

For patients under 70 years of age, the PBS indication for specific treatment, such as bisphosphonate therapy, is “established osteoporosis with minimal trauma fracture”. Thus, perhaps surprisingly, treatment is indicated for secondary prevention only. More remarkable is that patients do not need to have osteoporosis to receive the benefit: repeated enquiries to Medicare (the most recent on 3 March 2009) have confirmed that prior measurement of bone mineral density (BMD), the only practical way to diagnose osteoporosis, is not required. Yet it is well known that only 20% of women with peripheral fractures from non-major trauma actually have osteoporosis, whatever BMD T-score is used diagnostically.1

Accordingly, the current policy simultaneously denies specific treatment to patients with osteoporosis who have not yet sustained a fracture while subsidising treatment to patients with fractures who are unlikely to have osteoporosis. There is little gain from bisphosphonate therapy in women who have normal BMD and no vertebral fracture,2 but good evidence that such therapy is effective if BMD is low.3

To remedy these anomalies, we believe that bone densitometry should be more readily available — not deferred until people have fractures or reach the age of 70 years. We support a bone density measurement for all women at the menopause (and perhaps all men at age 60 years). This would identify those with osteoporosis at high risk of fracture as well as those in the low-normal range who are at high risk of developing osteoporosis.4 The first group could be offered specific therapy to prevent fractures and the second group could be advised on preventive lifestyle measures such as calcium and vitamin D supplementation and appropriate exercise. We estimate that the cost, even if there was full acceptance, would be only about $20 million a year compared with the current $8 billion yearly cost of osteoporotic fractures.5 Our recommended policy revision could pay for itself many times over, even if there were only a 10% reduction in fracture rate, not to mention improvements to be gained in the quality of patients’ lives.

Early recognition of low bone density and early diagnosis of osteoporosis has the long-term potential to transform the current depressing osteoporosis picture. We do not discount the importance of minimal trauma fracture, but believe that more weight should be given to vertebral fractures and less to peripheral fractures, as the former are much more likely to be osteoporotic, much more liable to recur,6,7 and much more responsive to specific therapies.3