What is the comparison of osteoporosis medications, including recommendations for treatment order?

From the Guidelines

Bisphosphonates are the recommended first-line treatment for osteoporosis, as they have the most favorable balance of benefits, harms, patient values, and cost 1.

Comparison of Osteoporosis Medications

• Bisphosphonates: alendronate, risedronate, ibandronate, and zoledronic acid are recommended as first-line treatments for osteoporosis due to their efficacy in reducing the risk of vertebral and non-vertebral fractures 1.
• Denosumab: a RANK ligand inhibitor, is suggested as a second-line treatment for patients with contraindications to bisphosphonates 1.
• Teriparatide: a recombinant PTH, and romosozumab: a sclerostin inhibitor, may be considered for patients at very high risk of fracture 1.
• Abaloparatide: a bone-forming agent, is considered an appropriate first-line treatment for men with osteoporosis at a very high risk of osteoporotic fracture 1.

Treatment Order

1. Bisphosphonates: initial pharmacologic treatment for primary osteoporosis 1.
2. Denosumab: second-line treatment for patients with contraindications to bisphosphonates 1.
3. Teriparatide or romosozumab: for patients at very high risk of fracture 1.
4. Abaloparatide: for men with osteoporosis at a very high risk of osteoporotic fracture 1.

Important Considerations

• Vitamin D and calcium repletion should be ensured in all men above the age of 65 years 1.
• Physical exercise and a balanced diet should be recommended to all men with osteoporosis 1.
• Serum total testosterone should be assessed as part of the pre-treatment assessment of men with osteoporosis 1.
• Appropriate hormone replacement therapy should be considered in men with low levels of total or free serum testosterone 1.

From the Research

Comparison of Osteoporosis Medications

• Osteoporosis medications include antiresorptives (e.g. bisphosphonates, denosumab) and anabolic agents (e.g. teriparatide, romosozumab) 2, 3, 4
• Bisphosphonates are the cornerstone of osteoporosis treatment, but their equivalencies and combinations have not been fully investigated 2
• Antiresorptive drugs, such as bisphosphonates and denosumab, increase bone mineral density (BMD) and reduce the risk of fractures 3
• Anabolic therapy with teriparatide has been shown to be superior to bisphosphonates in preventing vertebral and clinical fractures in postmenopausal women with vertebral fracture 3
• Romosozumab, a sclerostin antibody, increases BMD more profoundly and rapidly than alendronate and reduces the risk of vertebral and nonvertebral fracture in postmenopausal women with osteoporosis 3

Recommendations for Treatment Order

• Monotherapy with antiresorptive agents, particularly oral bisphosphonates, should be considered routinely as the first option for treatment of postmenopausal women 4
• In high-risk patients, anabolic agents may be considered as an initial therapeutic option 4
• Sequential treatment, starting with a bone-building drug (e.g. teriparatide), followed by an antiresorptive, may provide better long-term fracture prevention 3
• The combination of antiresorptive and anabolic agents may be useful to increase BMD, but more information is needed to determine the effects on fracture risk 4

Cost-Effectiveness of Osteoporosis Medications

• Economic evaluations have shown that oral bisphosphonates, such as alendronate and risedronate, are cost-effective in women with low BMD without previous fractures 5
• Denosumab has been found to be cost-effective in postmenopausal women and older men with osteoporosis, but its cost is higher than generic alendronate 5