There are few available treatments for osteoporosis – they can be divided into antiresorptive, bone-anabolic and dual-action treatment categories. All treatments reduce fracture risk, but the effect size and the time needed to see the effect differ between treatments and this should be taken into consideration when deciding on a treatment strategy for the individual patient.

For patients at high risk of fracture and high imminent fracture risk bone anabolic or dual action treatments are preferable as head-to-head studies comparing these treatments with bisphosphonates (VERO and ARCH trials) have demonstrated better protection against the next fracture in patients who already sustained a fragility fractures. These treatments are given for 1-2 years and should be followed by antiresorptive treatment.

For patients at moderate risk of fracture; patients without a fracture or a fracture many years ago, antiresorptive treatments would often be sufficient. For patients with very low BMD, a bone anabolic or dual action treatment should still be considered as it will not be possible to achieve BMD T-scores associated with low fracture risk with a bisphosphonate. If bone anabolic or dual action treatment can not be used, denosumab has the advantage of continued increase in BMD for at least up to 10 years.

Based on the SABRE study changes in BMD at the total hip seem to be the best predictor of fracture risk reduction in clinical trials. in addition, post hoc analyses of FREEDOM, HORIZON and FLEX trials have demonstrated that hip BMD T-scores about -2 or -2.5 provides some protection against future fractures – this has therefore recently been suggested as a target for osteoporosis treatment.

This also means that some patients who have obtained their treatment target can have a treatment pause or change to a treatment that can maintain the BMD. Treatment pause is only possible after long-term bisphosphonates. All other treatments need a transition to bisphosphonate for a period before a treatment pause. The length of the treatment pause is highly variable, probably depending on the severity of osteoporosis, age and duration of treatment. Some therefore prefer intermittent treatment with bisphosphonates instead of a pause with frequent controls.

Management of patients with osteoporosis requires a long-term treatment and monitoring plan that may include bone-anabolic treatment followed by antiresorptive treatment or the opposite sequence in case of deterioration of the condition. Patients with less severe disease can often be managed with antiresorptive treatment for a shorter or longer period of time. Treatment pauses may be possible in some patients but require monitoring.