Osteoporosis Treatment Guidelines

First-Line Treatment

The American College of Physicians recommends bisphosphonates as the first-line therapy for osteoporosis due to strong evidence showing reduction in hip fractures, clinical vertebral fractures, and radiographic vertebral fractures compared to placebo, with 6 fewer events per 1000 patients, 18 fewer events per 1000 patients, and 56 fewer events per 1000 patients, respectively 1, 3
Bisphosphonates are cost-effective and available in generic formulations, with a long-established safety profile despite rare adverse events 1, 3

The American College of Physicians recommends denosumab as second-line therapy for postmenopausal women and men with primary osteoporosis, with moderate-certainty evidence for postmenopausal women and low-certainty evidence for men 1, 2
Denosumab can be used in patients with impaired renal function, and has a convenient biannual subcutaneous administration of 60mg every 6 months 4, 5
Teriparatide is recommended as third-line therapy after bisphosphonates and denosumab, and is particularly useful in severe osteoporosis or patients with fractures, with increased new bone formation rather than just preventing resorption 4, 5, 6
Raloxifene is recommended only for postmenopausal women when other options are not appropriate, but has limitations due to lack of adequate data on benefits for vertebral and hip fractures, and potential harms including clotting risks 4, 6

Denosumab is preferred over bisphosphonates in patients with impaired renal function, and has shown efficacy in glucocorticoid-induced osteoporosis with 60mg subcutaneous injections every 6 months 4, 5
The treatment hierarchy for glucocorticoid-induced osteoporosis remains similar to that for primary osteoporosis, with oral bisphosphonates first, followed by IV bisphosphonates, teriparatide, and denosumab 5, 9
Adequate calcium and vitamin D intake, as well as lifestyle modifications including weight-bearing exercise, smoking cessation, and limiting alcohol intake, are recommended alongside pharmacological therapy 4, 6, 10

The American College of Physicians recommends the following treatment algorithm: