Osteoporosis Epidemiology, Diagnosis, and Management Across Race and Ethnicity in the United States

Abstract Osteoporosis is a systemic skeletal disease of reduced bone strength that leads to an increased risk of fragility fracture. Osteoporosis epidemiology, diagnosis, and management all are influenced by race and ethnicity. Studies have found approximately 40% to 50% lower fracture rates in Black and Asian as compared to White women. Hispanic women have generally been shown to have lower fracture rates than White women, but the magnitude of difference is uncertain. Studies in men are fewer. Substantial differences in bone density and structure contribute to these differences in fracture rates. The diagnosis of osteoporosis can be made by prior fragility fracture, bone mineral density T-score of less than or equal to −2.5, or by high calculated fracture score using the Fracture Risk Assessment Tool (FRAX). FRAX in the United States incorporates race, which has the effect of lowering calculated risk for Asian, Black, and Hispanic people by 0.43 to 0.64. In regard to pharmacotherapy, while not all trials have reported efficacy by race, there are not major known differences in osteoporosis treatment efficacy by race. Atypical femur fractures, rare subtrochanteric or diaphyseal fractures, are at least 6 times more common in Asian patients with antiresorptive therapies. Finally, there are important disparities in osteoporosis by race, including lower screening rates, lower treatment rates, and worse outcomes after fracture. Our review examines these racial differences in osteoporosis and provides an approach to incorporate race into the osteoporosis treatment algorithm. We advocate for a more aggressive approach to screening, treatment, and inclusion in research for patients of all races at risk of poor outcomes, acknowledging racial disparities in postfracture outcomes.