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Am Fam Physician. 2023;108(1):100-104

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Key Points for Practice

• Bisphosphonates, for up to five years orally or three years intravenously, are first-line therapy for osteoporosis.

• Denosumab injections every six months improve bone density more quickly than bisphosphonates, although bone density improvements fade within months after discontinuation unless bisphosphonates are started.

• Parathyroid hormone analog therapy for up to two years dramatically improves bone density and reduces fractures but requires subsequent bisphosphonate use to maintain benefit. 

• One year of treatment with romosozumab, a sclerostin-binding analog, followed by one year of alendronate reduces fracture risk more than two years of alendronate therapy alone.

From the AFP Editors

More than two-thirds of osteoporotic fractures occur in women, and one-half of postmenopausal women will experience an osteoporotic fracture. The American College of Obstetricians and Gynecologists (ACOG) has published new recommendations for managing this undertreated condition, including guidance on new medications and targeted treatments.

Health Inequities in Osteoporosis

Despite an increased risk of subsequent fracture within the first two years following a fracture, only one-fourth of women 60 years and older receive osteoporosis treatment during the first year. Black women are less likely than White women to receive treatment after diagnosis of osteoporosis, even after adjusting for insurance and socioeconomic status. Black women also have higher mortality in the year following a major fragility fracture.


Although osteoporosis can be diagnosed clinically after a fragility fracture from a fall of less than standing height, dual-energy x-ray absorptiometry is the preferred means of identifying bone loss before a fracture occurs. Dual-energy x-ray absorptiometry results are reported as a T-score of bone density referenced to healthy young women, and osteoporosis is identified at a T-score of −2.5.

Secondary Causes of Bone Loss

Osteoporosis can stem from secondary causes (Table 1). Although there is no direct evidence of benefit in patients with one or more of these factors or in patients with very low bone mineral density or a history of multiple or recent fractures, it may be appropriate to obtain a complete blood count, complete metabolic panel, thyroid-stimulating hormone level with or without free thyroxine, 25-hydroxyvitamin D level, and 24-hour urine collection for calcium, sodium, and creatinine excretion.

Conditions, disorders, and diseases
Anorexia nervosa
Diabetes mellitus (types 1 and 2)
Diminished ovarian reserve
Gastric bypass
Premature menopause (induced or surgical)
Primary ovarian insufficiency
Renal impairment
Rheumatoid arthritis
Turner syndrome
Vitamin D deficiency
Antiepileptic drugs (e.g., carbamazepine, phenobarbital, phenytoin, primidone [Mysoline])
Antiretroviral drugs
Aromatase inhibitors
Cancer chemotherapeutic agents
Depot medroxyprogesterone acetate*
Gonadotropin-releasing hormone agonists
Gonadotropin-releasing hormone antagonists

Indications for Medical Treatment

Medication is recommended for women with postmenopausal osteoporosis who have any of the following:

  • T-score of −2.5 or less for hip, lumbar spine, femoral neck, or distal third of radius

  • History of fragility fracture, including incidental or asymptomatic vertebral fracture

  • T-score between −1.0 and −2.5 and increased risk of fracture based on results from a clinical risk assessment tool, such as the Fracture Risk Assessment Tool (

Antiresorptive Agents

Antiresorptive agents decrease resorption of bone to increase bone density and are recommended for fracture prevention in most cases of osteoporosis.


Bisphosphonates inhibit osteoclast bone resorption and are the preferred initial therapy for osteoporosis. All bisphosphonates reduce vertebral fractures and most also reduce nonvertebral fractures (Table 2). Common adverse effects include musculoskeletal aches and pains, gastrointestinal irritation, esophageal reflux, and ulceration. Rare adverse effects include osteonecrosis of the jaw, atypical femoral fracture, and esophageal cancer.

CategoryDrug names (formulation)IndicationDurationAdverse effects
BisphosphonateAlendronate (oral)
Ibandronate (oral)
Risedronate (oral)
Zoledronic acid (Reclast; IV)
Preferred initial treatment
Following anabolic treatment or denosumab (Prolia)
High risk due to fragility fracture, hip T-score of −2.5 or less, or increased risk with risk tool: Consider up to 10 years of oral bisphosphonates and up to six years of IV zoledronic acid
Not high risk: Stop medication after five years of treatment with oral bisphosphonates and after three years of IV zoledronic acid
Atypical femoral fracture
Esophageal cancer
Esophageal reflux
Gastrointestinal irritation
Musculoskeletal aches
Osteonecrosis of the jaw
Targeted monoclonal receptor activator of nuclear factor kappa beta ligand inhibitorDenosumab (SC) every six monthsUnable to tolerate bisphosphonates due to adverse effects or decreased renal function
Patients with breast cancer at high risk of fracture
Studied for up to 10 years of use
No requirement to pause treatment but requires starting a bisphosphonate after discontinuation to avoid loss of bone density
Atypical femoral fracture
Osteonecrosis of the jaw
Selective estrogen receptor modulatorRaloxifene (oral)Desire for concomitant treatment to reduce risk of breast cancerStudied for up to eight years of use
Consider starting an antiresorptive agent such as a bisphosphonate after discontinuation
Death from stroke
Hot flashes
Leg cramps
Venous thromboembolism
Hormone therapyEstrogen with or without progesteroneFor prevention when bisphosphonates and denosumab are contraindicated
Patient younger than 60 years
Within 10 years of menopause
Bothersome menopausal symptoms
Low risk of venous thromboembolism, breast cancer, and coronary artery disease
Use the lowest effective dose for shortest duration necessary
Consider antiresorptive agent such as a bisphosphonate after discontinuation
Cognitive impairment
Increased cardiovascular disease (including stroke)
Increased risk of invasive breast cancer with estrogen-progestin
Estrogen, without progesterone, increases risk of endometrial cancer in women with a uterus
CalcitoninCalcitonin salmon nasal sprayRarely recommended
Postmenopausal osteoporosis in patients for whom alternative treatments are not an option
At least five years past menopause
Studied for up to five years of use
Consider starting an antiresorptive agent such as a bisphosphonate after discontinuation
Possible increased risk of malignancy
Parathyroid hormone analogAbaloparatide (Tymlos; SC)
Teriparatide (SC)
Consider as initial treatment for postmenopausal osteoporosis
At very high risk of fracture with T-score of −3.0 or less or multiple risk factors
Patients on antiresorptive therapy who continue to sustain fractures
Have persistent bone loss
Use for up to two years during lifetime
Requires antiresorptive agent such as a bisphosphonate after discontinuation
Possible increased risk of osteosarcoma if used more than two years in lifetime
Sclerostin-binding analogRomosozumab (Evenity; SC)Postmenopausal women with osteoporosis who are not at increased risk of cardiovascular disease or stroke
Who have a very high risk of fracture due to T-score of −3.0 or less or multiple risk factors
If other treatments have been ineffective
Use for up to one year
Requires antiresorptive agent such as a bisphosphonate after discontinuation
U.S. Food and Drug Administration boxed warning in patients with stroke or myocardial infarction in the past year
May increase risk of stroke, myocardial infarction, or cardiovascular death

Oral bisphosphonates are poorly absorbed and must be taken on an empty stomach at least 30 minutes before eating. The patient should remain upright for 30 minutes to avoid esophageal irritation. Oral bisphosphonates are contraindicated in patients with hypocalcemia, esophageal disorders, and gastrointestinal malabsorption (e.g., gastric bypass), but intravenous bisphosphonates can generally be used. All bisphosphonates are contraindicated in patients with chronic kidney disease that has progressed to an estimated glomerular filtration rate of 35 mL per minute or less.

Because prolonged use of bisphosphonates is associated with increased risk of femoral fracture and possibly osteonecrosis of the jaw, stopping after five years of oral treatment or three years of intravenous treatment is recommended. Limited evidence suggests that treatment beyond these time frames does not reduce the likelihood of nonvertebral fractures. In patients at high risk of fracture due to previous osteoporotic fracture or a hip T-score of −2.5 or lower, or with increased risk based on risk assessment tool results, longer initial treatment of up to 10 years for oral bisphosphonates and up to six years for intravenous zoledronic acid (Reclast) is suggested. Duration of drug holidays is unclear; however, expert opinion recommends two to four years. Therapy can later be restarted if the risk of fracture increases.


Denosumab (Prolia) is a human monoclonal antibody that inhibits the receptor activator of nuclear factor kappa beta ligand to reduce osteoclast activity. The recommendations suggest offering denosumab to patients who prefer an injection every six months over oral therapy. It can also be used in patients with chronic kidney disease or patients with breast cancer treated with aromatase inhibitors. Like bisphosphonates, denosumab rarely can lead to osteonecrosis of the jaw and atypical femoral fractures and is contraindicated in people with a history of either.

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Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, associate medical editor.

A collection of Practice Guidelines published in AFP is available at

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