How to optimize the use of anti-osteoporotic medication in clinical practice?

Pharmacologic treatment to reduce the risk of fractures focusses on the bone component of fracture risk. We present a narrative review for clinicians to optimize drug treatments in six frequently occurring clinical situations with a high/very high fracture risk.

We reviewed drug treatment in postmenopausal women according to their fracture risk before a clinical fracture, after a recent clinical non-hip and after a hip fracture, and in GC users and the treatment targets to optimize the choice and sequence of drugs and to develop lifelong follow-up and treatment strategies. New data are available to guide the choice of start and sequence of anti-resorptives and osteo-anabolics according to the level of fracture risk in postmenopausal women, in patients treated with glucocorticoids, after a hip fracture and in patients treated with a treat to target strategy.

Integrating FRAX, the level of aBMD, a detailed fracture history including imaging of the spine, and additional risk factors contributes to decide on treatment with antiresorptive-treatment (in high-risk subjects) and osteoanabolic-treatment (in very high-risk subjects) and their sequence to achieve a target with a low fracture risk which needs lifelong follow up for further diagnostic and treatment decisions.