根據葡萄牙風濕病學會（the Portuguese Society of Rheumatology，SPR）在2018年的建議 (Rodrigues AM 2018 )。

【骨鬆Q&A 005】我們知道使用BMD 作為單一評估標準是有問題的。這個問題出現在診斷過程及考慮需不需要開始藥物治療。現在我們來看看學理上何時應該開始藥物治療。

SPR認為開不開抗骨質疏鬆藥物的決定，應該基於FRAX®Port工具估計的個體隨後發生骨質疏鬆性骨折的十年風險。

上述治療風險閾值基於成本效益分析，適用於最經濟的治療方案：通用Alendronate。

更昂貴的藥物具有更高成本效益的干預門檻 (Marques A 2016)。

先前脆性骨折的患者（尤其是髖關節）將顯著降低藥物治療後發生脆性骨折的風險，而與骨密度無關 (VERT FIT trial)  (Black DM 1996, Harris ST 1999, Reginster J 2000, Neer RM 2001, Chesnut CH 2004, Kanis JA 2005, Lyles KW 2007, Cummings SR 2009)。小魏醫師再次強調骨質疏鬆症的治療是在降低骨折風險，而不是治療骨質密度，這是基層醫師最常犯的錯誤。

值得注意的是，一些國際建議，即使無症狀，在出現椎體畸形2級（即錐體高度減少> 25-40％）的情況下也應開始治療 (Black DM 2000)。

專家們意識到許多國際建議表明DXA T評分≤-2.5的患者也應接受治療，不論FRAX®和年齡 (Papaioannou A 2010, Kanis JA 2013, Cosman F 2014, Camacho PM 2016, Rossini M 2016)。

這些建議是基於這樣一個原則，即是在藥物治療的基礎下，減少股骨頸或腰椎T值達到-2.5或更低的骨折風險 (Reginster J 2000, McClung MR 2001, Neer RM 2001, Rossouw JE 2002, Sorensen OH 2003, Anderson GL 2004, Bone HG 2004, Miller PD 2005, Black DM 2006, Reginster JY 2006, Black DM 2007, Lyles KW 2007, Eisman JA 2008, Cummings SR 2009)。

根據葡萄牙多學科建議，SPR不認可這一政策，因為低BMD不一定與骨折的重大風險相關，特別是在年輕人中 (Marshall D 1996, Johansson H 2009)。

小魏醫師總結，國際專家對於治療與否，專注在幾個因子，包括FRAX、BMD、fragility fracture脆性骨折。其中以FRAX最為重要，因為它包含一般的危險因子評估，一次作齊，很少疾病有如此方便的大數據評估工具。https://www.sheffield.ac.uk/FRAX/tool.aspx?country=26

一旦FRAX接近治療閥值，再進一步評估BMD及骨折狀況，根據國家健康政策規範治療。

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