Introduction

Osteoporosis is a chronic disease characterized by bone fragility and fractures. Osteoporosis represents a relevant global public health problem, which is projected to increase in magnitude in the next 10 years. Fortunately, substantial advances in the diagnosis and treatment of osteoporosis have emerged in the last decade and we have now the knowledge and instruments to tackle the ongoing osteoporosis crisis. In the present review, we will mainly focus on forecasts on the epidemiology of and costs related to osteoporosis in the next decade and we will discuss on the future of osteoporosis diagnosis, fracture risk assessment, and treatment.

Epidemiology and costs of osteoporosis in 10 years from now

Osteoporosis represents a major worldwide clinical, societal, and economical challenge. Osteoporosis prevalence and burden are projected to increase in the following years, mainly in relation to the aging of the population. Scorecard for Osteoporosis in Europe (SCOPE) is an international project aimed to determine the burden of osteoporosis across Europe. ¹ The SCOPE panel, which was first established in 2010 and updated in 2021, evaluates the information regarding osteoporosis in 29 countries through structured questionnaires (27 European countries, the United Kingdom, and Switzerland). ² The SCOPE data provides a comprehensive picture of what is happening nowadays in Europe in terms of osteoporosis burden and can help forecast what will happen in the next decade. The total direct costs related to osteoporosis care (fragility fracture treatment and pharmacological costs) amounted to an astonishing cost of €37.4 billion in 2010, which increased to an even greater amount in 2019 (€56.9 billion, +64%). This observed increase was consistent with 50% increase in costs by 2025 proposed in 2007. ³ In their study, Burge et al. used Markov decision models to estimate fracture costs over two decades (2005–2025). What is noteworthy and, at the same time, disheartening, is that despite the cost of osteoporosis care, the pharmacological and assessment costs decreased from €2.1 billion in 2010 to €1.6 billion in 2019. Moreover, the costs of Quality Adjusted Life Years (QALYs) lost were not included in the latter estimation of costs. Indeed, the overall costs were even higher when QALYs were included. QALYs lost costs amounted to an overwhelming total of €112.9 billion, resulting in a €169.8 billion of direct and indirect costs related to osteoporosis in 2019. The disparity between costs related to fragility fracture care and pharmacological costs is startling and becomes even more evident when compared with other noncommunicable diseases. Indeed, the pharmacological treatment for cardiovascular diseases represented approximately one quarter of the total expenditures, a proportion that is considerably higher than that for osteoporosis (2.8%).

Osteoporosis is estimated to affect more than 30 million persons in Europe and a similar number of individuals in the United States.^4,5 The vast majority of these are women. However, studies at population level could underestimate the true prevalence of a silent disease such as osteoporosis. Indeed, osteoporosis prevalence strictly depends on screening availability. Screening strategies with standard dual-energy X-ray absorptiometry (DXA) in women aged more than 50 years have been implemented in most western countries but remain underutilized in many other developing countries. ⁶ Moreover, osteoporosis in men is still largely underdiagnosed, and the diagnosis is commonly made in the presence of a fragility fracture. Concerningly, the proportion of patient living with osteoporosis worldwide is increasing.

Fragility fractures are the consequence of osteoporosis and reducing their incidence represents the primary outcome for all interventions. More than 4 million fractures have been reported each year in Europe in the last 5 years. These numbers are projected to increase substantially in the next 10 years. In fact, the SCOPE analysis has estimated that the overall number of fractures will increase by 20% by 2035. In addition, simulation models have been used to predict the future burden of fragility fracture. A recent study by Cui et al. showed that, in China, the annual number of fragility fracture will increase by 135% by 2040, while the proportion of population >50 years will increase by approximately 100%. This increase is partially preventable by adoption of relatively simple and cost-effective strategies, such as increased awareness about the availability of pharmacological options and interventions aimed to improve treatment adherence.^7–10

In summary, the burden of osteoporosis and fragility fractures is projected to increase at a dramatic pace in the next decade taking in consideration the effect of the aging of the population alone. Of concern, there are individual and environmental factors that can further augment this trend. As an example, obesity and diabetes, which have increased in prevalence worldwide, have been largely associated with higher risk of fracture independently from bone mineral density (BMD).^11–13 Sedentary lifestyle in younger individuals has also been associated with increased risk of osteoporosis later in life. ¹⁴ Moreover, environmental air pollution, a well-known issue for present and future generations, ¹⁵ has been linked with a substantial increase in the risk of osteoporosis and fractures.^16,17 However, effective interventions exist to help mitigate the challenges posed by increased osteoporosis prevalence. Lifestyle modifications for healthy bones should be advised for all populations, screening strategies should be implemented and harmonized across countries, treatment accessibility should be improved, and treatment adherence should be encouraged.