Osteoporosis Treatment Guidelines

Comparison of Efficacy

The American College of Physicians recommends bisphosphonates as first-line treatment for osteoporosis due to their superior efficacy in reducing fracture risk, with 6 fewer hip fractures, 18 fewer clinical vertebral fractures, 24 fewer any clinical fractures, and 56 fewer radiographic vertebral fractures per 1000 patients compared to placebo 1, 2
Bisphosphonates have the most favorable balance among benefits, harms, patient values and preferences, and cost among all drug classes evaluated for osteoporosis treatment 2
Alendronate, risedronate, and zoledronic acid have demonstrated efficacy in reducing both vertebral and non-vertebral fractures 1, 2
Teriparatide reduces risk of any clinical fractures, radiographic vertebral fractures, and clinical vertebral fractures, with 27 fewer events per 1000 patients, 69 fewer events per 1000 patients, and 45 fewer events per 1000 patients, respectively 3
Compared to bisphosphonates, teriparatide reduces radiographic vertebral fractures and may reduce any clinical fracture, with 66 fewer events per 1000 patients and 46 fewer events per 1000 patients, respectively 3

High-certainty evidence shows no differences between bisphosphonates and placebo in serious adverse events and withdrawals due to adverse events at least 3 years after treatment initiation 1
Bisphosphonates are associated with higher risk for atypical femoral fractures and osteonecrosis of the jaw, although observed events were uncommon, with 0.01% to 0.3% of users 1, 2
Oral bisphosphonates may cause esophageal irritation and should be avoided in patients with esophageal varices 6

The American College of Physicians recommends bisphosphonates as first-line therapy, with alendronate, risedronate, or zoledronic acid as options, due to their cost-effectiveness and strong recommendation for postmenopausal women 1, 2, 4
RANK ligand inhibitor, such as denosumab, is recommended as second-line therapy for patients with contraindications to or adverse effects from bisphosphonates 4, 8
PTH analogue, such as teriparatide, or sclerostin inhibitor, such as romosozumab, is recommended as third-line therapy for very high fracture risk, followed by a bisphosphonate 3, 4

Bisphosphonates are significantly less expensive than other osteoporosis medications 1
Oral bisphosphonates should be taken on an empty stomach, 0.5–2 hours before food and other drugs, and at a different time than calcium supplements 6
Typical bisphosphonate therapy duration is 5 years, with consideration for interrupting therapy after 5-10 years 5
After completing teriparatide treatment, patients should transition to a bisphosphonate to maintain bone density gains 3
All patients should receive adequate calcium and vitamin D supplementation, with 1,000-1,200 mg daily and 600-800 IU daily, respectively 5