In reply: Seeman and colleagues agree that most patients with minimal trauma fractures do not have osteoporosis. The figures are clear: only 13% of patients with a peripheral fracture have a hip bone mineral density (BMD) T-score less than or equal to − 2.5 and only 25% have a score less than or equal to − 1.5. The corresponding figures for vertebral fractures are 25% and 38%, respectively.1 We do not argue that the − 2.5 T-score threshold for defining osteoporosis is sacrosanct, but simply that some bone density threshold be defined for subsidised therapy, for which virtually all the supporting evidence is based on treatment of patients with established osteoporosis. Osteopenia is an artificial concept with an arbitrary definition, but we agree that the T-score threshold for subsidised therapy need not be as low in those with prevalent adult fracture as in those without — perhaps − 1.5, which is the threshold recently adopted for patients receiving corticosteroid therapy.
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