The Treatment Gap in Very High-Risk Osteoporosis: Bridging the Disconnect Between Guidelines and Practice

A "Tremendous Gap" in Osteoporosis Care

Osteoporosis management has shifted significantly in recent years, moving away from a "one-size-fits-all" approach toward stratified care based on individual fracture risk. Yet, a 2025 report published in Endocrinology Advisor and summarized by Medscape identifies a significant discrepancy between clinical guidelines and real-world prescribing habits, particularly among women identified as "very high risk" for fragility fractures.

The study, which analyzed millions of patient records, revealed that more than half of women classified as "very high risk" were prescribed treatments that did not align with current first-line guideline recommendations. Instead of receiving potent anti-resorptive or anabolic therapies suited for severe bone disease, many were continued on standard regimens—or prescribed nothing at all—highlighting a persistent gap in evidence-based care for this vulnerable population.

Redefining "Very High Risk"

To understand the treatment gap, one must look at how risk categories have evolved. In 2025, consensus statements such as the Singapore Consensus Statement on Management of Osteoporosis emphasized the need for "rapidly escalating" treatment pathways for patients with specific high-risk features.

Women are categorized as "very high risk" if they present with:

• A prior hip or vertebral fracture.
• Multiple prior fractures.
• Fractures occurring while already on anti-osteoporotic treatment (breakthrough fractures).
• High FRAX scores combined with severe femoral neck T-scores.

Current major clinical guidelines, including those from the National Osteoporosis Foundation (NOF), typically recommend immediate treatment with potent agents. For very high-risk patients, this often involves prioritizing anabolic (bone-building) agents like teriparatide or abaloparatide, or switching to a highly potent anti-resorptive like intravenous zoledronic acid to ensure rapid efficacy and strict adherence.

Barriers to Appropriate Prescribing: Omission Bias

If the guidelines are clear, why is there a gap? A contributing factor appears to be the prevalence of "omission bias" among clinicians—a cognitive heuristic where decision-makers prefer inaction over action that might result in potential harm, even if that inaction carries greater risks.

Research cited in a January 2025 article in Frontiers in Medicine highlighted that while osteoporosis treatments like bisphosphonates have a robust safety record, occasional media coverage of rare adverse events (such as atypical femoral fractures or osteonecrosis of the jaw) has influenced prescribing behaviors. Many clinicians exhibit a hesitancy to prescribe aggressive therapy to elderly women who they perceive as "fragile" or who express anxiety about medication side effects.

This caution often leads to a default choice of oral bisphosphonates, which require daily dosing and dietary restrictions, or calcium and vitamin D supplementation alone. While safer in terms of local side effects, these interventions are statistically less effective at preventing subsequent catastrophic fractures in "very high risk" patients compared to anabolic agents or intravenous therapies.

Consequences of Misalignment

The implications of this treatment gap are substantial. Fragility fractures, particularly of the hip, carry high morbidity and mortality rates. A follow-up fracture within a short period can lead to loss of independence and increased mortality.

When a woman with a prior vertebral fracture—who is already in the highest risk tier—is prescribed a standard preventative dose rather than a targeted, potent intervention, her residual risk remains unacceptably high. As noted in The Lancet's 2025 epidemiology reviews, untreated or under-treated osteoporosis continues to account for millions of disability-adjusted life years annually, disproportionately affecting women.

Patient-Facing Implications

For patients navigating the healthcare system, recognizing these disparities allows for more proactive engagement with providers. Because clinical inertia often drives prescription patterns, patients at elevated risk should consider asking the following questions:

1. "What is my absolute fracture risk?"

Patients should request a FRAX assessment or a similar evaluation that considers their personal history of falls, family history, and baseline bone density (DEXA scan).

2. "Are my current medications appropriate for my risk level?"

If you have suffered a fracture recently or have been on medication without stopping new fractures, ask your physician if you qualify for "anabolic-first" therapy or a switch to a different class of anti-resorptives.

3. "How do we weigh the risks of side effects?"

Discussing fears of rare complications openly can help build trust. Understanding that the statistical benefit of preventing a hip fracture far outweighs the rare risks of modern bone-building drugs can reassure both patient and clinician.

Conclusion

The "tremendous gap" in osteoporosis care underscores the necessity of moving beyond static diagnostic labels. Effective women's health policy and clinical practice must prioritize dynamic risk assessment. Closing this gap requires clinicians to move past omission bias and recognize that for the "very high risk" patient, standard care is often insufficient care.