Osteoporosis treatment

Treat pharmacologically when fracture risk is high: a T-score of -2.5 or lower at the spine, femoral neck, total hip, or one-third radius; or a prior hip or vertebral fragility fracture with a T-score between -1.0 and -2.5; or a T-score in that range with a US-adapted FRAX 10-year risk of at least 20 percent for major osteoporotic fracture or 3 percent for hip fracture. The Endocrine Society and the Bone Health and Osteoporosis Foundation use the same thresholds. ACP 2023 deliberately does not adopt a numeric cutoff and instead weighs diagnosis, fracture history, and multiple risk factors.

Bisphosphonates (alendronate, risedronate, or zoledronate) are first-line to reduce fracture risk (ACP strong, high-certainty; the Endocrine Society and AACE agree). Ibandronate is not shown to reduce hip or nonvertebral fractures. Reassess fracture risk at 3 to 5 years.

Denosumab is an effective antiresorptive: an alternative first-line option for the Endocrine Society and AACE, while ACP places it second-line after bisphosphonate intolerance or contraindication. Load-bearing safety point: do not delay or stop denosumab without transitioning to another antiresorptive such as a bisphosphonate, because stopping causes rebound bone loss and multiple vertebral fractures.

For very high fracture risk, such as a recent fracture, multiple vertebral fractures, or a very low T-score, start with an anabolic agent: teriparatide or abaloparatide for up to 2 years, or romosozumab for up to 1 year (avoid romosozumab with a recent myocardial infarction or stroke or high cardiovascular risk). Always follow an anabolic with an antiresorptive to preserve the gains. Bisphosphonate drug holiday: reassess oral bisphosphonates at 3 to 5 years and consider a holiday if risk is no longer high, while continuing in those who stay high-risk; end the holiday if fracture risk rises or bone density falls.