Osteoporosis Medication Risks and Considerations

Introduction to Osteoporosis Medication Risks

The American College of Physicians recommends that bisphosphonates show no difference in serious adverse events or withdrawals compared to placebo in randomized controlled trials (high to moderate certainty evidence) 2
The American College of Physicians states that osteonecrosis of the jaw and atypical femoral fractures occur with higher risk after longer treatment duration (low certainty evidence from observational studies) 2
The American College of Physicians suggests that extending bisphosphonate therapy beyond 3-5 years reduces vertebral fractures but increases long-term harms without reducing hip or other non-vertebral fractures 1, 3, 4, 5
The American College of Physicians recommends that after 5 years of continuous therapy, clinicians should reassess fracture risk and consider a drug holiday unless the patient has strong indications for continuation (history of vertebral fracture, T-score ≤-2.5, or ongoing very high fracture risk) 1, 3, 4, 5, 6

The American College of Physicians states that teriparatide may increase the risk of serious adverse events and probably increases withdrawal due to adverse events (low to moderate certainty evidence) 2
The American College of Physicians suggests that long-term safety in humans requires ongoing evaluation 1, 4
The American College of Physicians states that abaloparatide's long-term safety in humans has yet to be determined, making evidence inconclusive for recommendation 1, 4
The American College of Physicians suggests that romosozumab followed by alendronate probably does not increase risk for serious harms or withdrawal compared to bisphosphonate alone at 12-36 month assessment (moderate to low certainty evidence) 2

The American Geriatrics Society states that older adults (≥65 years) with osteoporosis face increased risk for falls and adverse events due to polypharmacy or drug interactions 1, 3, 4, 5
The American Geriatrics Society recommends that treatment selection must address contraindications and cautions based on comorbidities and concomitant medications 1, 3, 4, 5

The American College of Physicians states that evidence on benefits and harms of raloxifene and bazedoxifene remains inconclusive for making firm recommendations 1, 4

The American College of Physicians recommends that all patients require calcium 1000-1200 mg daily and at least 400-800 IU vitamin D daily to reduce hypocalcemia risk 7, 6
The American College of Rheumatology suggests that BMD testing should be performed every 1-3 years during treatment in high-risk patients 8, 7
The American College of Physicians states that for patients who completed osteoporosis treatment, BMD testing should occur every 2-3 years 8
The American College of Physicians recommends that the decision for bisphosphonate holiday and its duration must be individualized based on baseline fracture risk, medication type and bone half-life, benefits versus harms, and higher fracture risk from discontinuation 1, 3, 4, 5