Bone Anabolic Treatment in Older Subjects: A Narrative Review

The combination of an increasing life expectancy and an increasing risk of fractures in the aging population collides with the still inadequate primary and secondary fracture prevention in Europe. Osteoporotic fractures have a major impact not only on morbidity, quality of life, and mortality but also on healthcare costs. Therefore, an improvement of fracture prevention is warranted. Osteoanabolic drugs are particularly beneficial in patients with very high fracture risk and are recommended by numerous current guidelines as first-line treatment options.

Osteoanabolic treatment leads to a significant improvement in bone mineral density (BMD), microstructure, and biomechanics. A superiority compared to antiresorptive treatment options has been demonstrated in clinical trials. However, the application of these therapies in the geriatric population addresses specific questions regarding efficacy, safety in terms of comorbidities, and feasibility regarding the route of administrations. Overall, post hoc analyses in this patient population demonstrate promising and comparable outcomes with respect to safety, fracture risk reduction, and improvements in BMD. However, data are limited and especially in romosozumab the contraindication in patients with a history of stroke or myocardial infarction should be kept in mind. Furthermore, a promising new anabolic oral treatment is currently under development and would further increase the armamentarium of osteoanabolic options. Osteoanabolic agents show positive effects on fracture healing and perioperative management for instrumentation surgery.

Osteoanabolic therapies should be individually evaluated in all patients with a very high risk for fracture, especially in the context of sequential therapy, since fracture risk declines rapidly, which is warranted not only for the individual health outcome but also for socioeconomic aspects. This narrative review aimed to provide a comprehensive overview of the efficacy and safety of the anabolic osteoporosis agents teriparatide, abaloparatide, and romosozumab in older individuals.