[Osteoporosis-Update 2021]

The state of the art of osteoporosis management and treatment is being continuously refined according to recent progress in data availability, drug development and strategies as determined by health authorities. The recent approval of the sclerostin-antibody romosozumab as a novel first in class anabolic drug is another milestone that enriches our therapeutic portfolio. Neutralisation of the wnt-pathway inhibitor sclerostin by romosozumab leads to rapid stimulation of bone formation and a rise in bone mineral density that translates into robust > 70 % reduction of fracture risk at the lumbar spine. Already after one year of treatment romosozumab is stopped and followed by antiresorptive maintenance treatment. The indication for this strategy is severe osteoanabolic compounds can now be applied as a first line treatment without prior antiresorptive medication. The new data helped in alleviating restrictions by the authorities for first line use of anabolic strategies. Romosozumab and teriparatide represent two anabolic strategies that differ in their mode of action although the molecular mechanisms are partially overlapping. Teriparatide is primarily active as a remodeling agent whereas romosozumab exerts bone mass gains mainly via modeling. Differential therapeutic strategies throughout a patient "career" may take into account these differences as well as adverse effects and individual contraindications. Based on all our recent progress and achievement we can more and more individualize the long term management of osteoporosis over decades applying an individual "treat to target" strategy. Basically, osteoporosis is a chronic disease and has to be treated as such. If however for whatever reason treatment regimens using biologicals are being discontinued we have to be aware that such situations need to be stabilized using long-acting bisphosphonates to maintain the therapeutic success and avoid rapid bone loss and fracture risk.