The Big Clinical Session at the forthcoming meeting of ECTS in Valencia is dedicated to two highly topical issues related to the clinical management of osteoporosis. In the first of these Cyrus Cooper (picture on the right), Director & Professor of Rheumatology, MRC Lifecourse Epidemiology Unit and Professor of Epidemiology, University of Oxford, will address the under-treatment of osteoporosis, focussing on models of service delivery that can improve treatment rates and outcomes. The second talk in the session, given by Lorenz Hofbauer (picture on the bottom left), Professor of Endocrinology, Diabetology and Bone Diseases, at the University of Dresden, will review current and emerging anabolic therapies to reduce fracture risk, and the role of sequential treatment to prolong benefits.
There is universal agreement that bone protective therapy should be advised in people at very high risk of fracture, for example those who have recently sustained a vertebral or hip fracture. However, data from many parts of the world indicate that treatment rates in such people are suboptimal and may even be decreasing. The reasons for this are multiple and complex, but integrated care pathways that identify, investigate and treat this high-risk population have been shown to be 
cost-effective. There is now a concerted effort to implement such services more widely and to address concerns about side effects such as atypical femoral fractures and osteonecrosis of the jaw, which have a significant impact on prescribing of treatment and on patient uptake and adherence. These and other aspects of the treatment gap will be reviewed by Professor Cooper in his talk.
One of the exciting advances in recent years has been the development of drugs with different mechanisms of action to reduce fracture risk. In particular, anabolic agents have been shown to be effective in decreasing the risk of fracture and comparator trials suggest that they are more effective than anti-resorptive agents in people at high risk of fracture. There is therefore a rationale for using anabolic therapy as the first line option in some patients. However, because the duration of treatment with these drugs is limited by regulatory or other considerations, sequential therapy is required to maintain the benefits gained. These new treatment paradigms are the subject of much discussion at present and will be debated by Professor Hofbauer, with up-to-date information on their efficacy, safety and potential cost-effectiveness.