Category	Drug names (formulation)	Indication	Duration	Adverse effects
Bisphosphonate	Alendronate (oral) Ibandronate (oral) Risedronate (oral) Zoledronic acid (Reclast; IV)	Preferred initial treatment  or 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 inhibitor	Denosumab (SC) every six months	Unable 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 modulator	Raloxifene (oral)	Desire for concomitant treatment to reduce risk of breast cancer	Studied 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 therapy	Estrogen with or without progesterone	For prevention when bisphosphonates and denosumab are contraindicated  and Patient younger than 60 years  and Within 10 years of menopause  and Bothersome menopausal symptoms  and 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
Calcitonin	Calcitonin salmon nasal spray	Rarely recommended Postmenopausal osteoporosis in patients for whom alternative treatments are not an option  and 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 analog	Abaloparatide (Tymlos; SC) Teriparatide (SC)	Consider as initial treatment for postmenopausal osteoporosis  and At very high risk of fracture with T-score of −3.0 or less or multiple risk factors  or Patients on antiresorptive therapy who continue to sustain fractures  or 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 analog	Romosozumab (Evenity; SC)	Postmenopausal women with osteoporosis who are not at increased risk of cardiovascular disease or stroke  and Who have a very high risk of fracture due to T-score of −3.0 or less or multiple risk factors  or 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