Osteoporosis and fracture risk increase exponentially in postmenopausal females. This places a significant burden in terms of morbidity, mortality and costs that are likely to increase with an ageing population. Despite this there is very limited data on pharmacological management of osteoporosis in this high risk group.Objectives of this reviewTo review the published literature on the clinical efficacy and safety of specific anti osteoporosis treatments in the reduction in fracture risk in females ≥ 75 years of age. The following major endpoints were used in this review:1. Vertebral fracture reduction at 1 year and 3 years.2. Non-vertebral fracture and hip fracture reduction at 1 year and 3 years.3. Safety data in this group.Search methods for identification of studiesWe performed an electronic search of Medline (1970 to June 2007) and the Cochrane Library (1996 to June 2007). Our search strategy included MeSH terms for osteoporosis and treatments. We reviewed the reference list of identified articles for additional relevant published trials.ResultsTwo hundred and fifty-two potentially relevant abstracts were identified. Only six publications were deemed to meet full eligibility criteria and one met most criteria. There is evidence for significant vertebral fracture relative risk reduction(RR) at 1 year for Risedronate (RR 81%; p <0.001), Teriparatide (RR 65%; p <0.05) and Strontium Ranelate (RR 59%; p = 0.002) and 3 years for Risedronate (RR 44%; p = 0.003), Alendronate (RR 38%; p <0.05) and Strontium Ranelate (RR 32%; p = 0.013). There is evidence for significant non-vertebral fracture relative risk reduction at 1 year for Strontium Ranelate (RR 41%; p = 0.027) but not Teriparatide (p = 0.66) and 3 years for Strontium Ranelate (RR 31%; p = 0.011) but not Risedronate (p = 0.66). The only study to report a reduction in hip fracture at 3 years is the TROPOS study with Strontium Ranelate (RR 36%; p = 0.046).DiscussionThis review reinforces the irony that the least evidence is available for fragility fracture reduction in the group at greatest risk; the old old and those with non vertebral and hip fracture. Although there is good evidence for the benefit of the bisphosphonates (Alendronate and Risedronate), Teriparatide and Strontium Ranelate in vertebral fracture reduction, there are very limited data for non vertebral and hip fracture reduction. Strontium Ranelate is the only agent to date that has demonstrated a reduction in non vertebral and hip fracture events in this high risk elderly female population. Perhaps we need to adopt different strategies in managing older patients with osteoporosis as their fracture risks and treatment strategies may be quite different from younger populations.