The evaluation of metabolic state is thought to be useful for the risk evaluation of fractures and early evaluation of treatment effects. The evaluation may also be useful to maintain adherence to osteoporosis treatment, especially in patients without symptoms. The most markers are reimbursed, although number and timing of the evaluation are limited. The guidelines are published, and it is common practice to evaluate metabolic conditions of osteoporotic patients. They are especially useful to decision making for treatment not only in patients but also in physicians. The follow-up evaluation of the markers is useful in patients treated with bisphosphonate, raloxifene and/or vitamin K2 to maintain adherence.

There has been accumulating evidence that various diseases and drugs cause increased risk of fracture. Although the treatment of primary diseases and discontinuation of drugs are the first and ideal option for the cure of secondary osteoporosis, medical intervention for osteoporosis is often necessary. The mechanisms, which induce bone fragility, are supposed to be different, depending on diseases and drugs. Guidelines for the evaluation and treatment of secondary osteoporosis have not been established except glucocorticoid-induced osteoporosis. In patients with osteoporosis caused by primary hyperparathyroidism, hyperthyroidism, diabetes mellitus as well as hormone deprivation therapy, bisphosphonate is effective in increasing bone mineral density but no data have been available about the fracture risk. Guidelines on the management and treatment of each secondary osteoporosis are desirable.

The incidence of osteoporotic fractures increases along aging and the importance of their prevention is more emphasized in the elderly. Although the major determinants for fragile fractures in the elderly are not only the lower bone strength but also frailty and fall, treatments with anti-resorbers are effective also in the elderly. On the other hands, nutritional agents such as active vitamin D3 and vitamin K2 are effective in reducing the fracture incidences in spite of their modest effects on bone mineral density. Recently, the effects of vitamin Ds on the reduction of fall events are noticed and the prevention of osteoporotic fractures in the elderly through extra-skeletal mechanisms seems promising.

Osteoporosis is the most frequent adverse effect of glucocorticoids. Management guidelines for glucocorticoid-induced osteoporosis have been established in the United States, the United Kingdom, and many other countries. The 2004 edition of the guidelines on the management and treatment of glucocorticoid-induced osteoporosis have been proposed by The Japanese Society for Bone and Mineral Research. The subjects were patients with using or planning to use oral glucocorticoids for 3 months or longer. The criterion for starting treatment was patients with prior fragility fracture and with new fractures during treatment, patients with less bone mineral density (BMD) than 80% of young adult mean, and patients with using as a dose of 5mg/day or higher (mean daily dose) as prednisolone equivalent. The bisphosphonates have been recommended as first-line drugs and active vitamin D(3) and vitamin K(2) have been recommended as second-line drugs.

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