Medications and fracture prevention

How I think about the conversation

People sometimes feel that needing an osteoporosis medicine means they failed at prevention. I do not see it that way. When fracture risk is high enough, medication is best understood as one part of a prevention plan, alongside fall prevention, strength, nutrition, and evaluation for secondary contributors.

The right choice depends on the whole clinical picture: fracture history, DXA results, age, kidney function, other medical conditions, dental considerations, prior medications, side effects, and how high the fracture risk appears to be.

The main categories

Some medications slow bone breakdown. Others help build bone. Many patients start with an antiresorptive medication such as a bisphosphonate or denosumab. People at very high fracture risk, including some with recent or multiple fractures, may need a conversation about an anabolic-first strategy followed by antiresorptive therapy.

This is exactly the kind of decision that should be made with a clinician who knows your history. A website can explain the categories. It cannot choose for you.

Questions worth asking

• What makes my fracture risk low, moderate, high, or very high?
• Am I a candidate for medication now, or do we need more information first?
• What benefits are we hoping for, and over what time period?
• What side effects or rare risks should I understand?
• How long would treatment last, and what happens after that?

Evidence review

Biology

Osteoporosis medications work through different biology. Antiresorptive medicines slow bone breakdown; anabolic or bone-forming medicines stimulate new bone formation or improve formation balance. The right question is not whether medicine is good or bad, but whether the expected fracture-risk reduction is worth the specific risks for that patient.²³

Risk stratification

Medication is most compelling when fracture risk is high: prior hip or vertebral fracture, multiple fragility fractures, very low BMD, high FRAX probability, glucocorticoid exposure, or other major secondary causes. Lower-risk patients may be better served by monitoring and foundational measures while risk is clarified.²

Sequencing and duration

Sequencing matters. Starting with an anabolic agent may be considered for very high-risk patterns, while antiresorptives remain important for many patients. Denosumab requires a clear transition plan if stopped, and bisphosphonate holidays are considered only in selected lower-risk patients after adequate treatment.⁴⁷³⁹

Treatment strategy

A good plan includes medication choice, dental and renal context, calcium and vitamin D adequacy, exercise and fall-risk work, adherence support, and a follow-up plan. After fracture, fear that medication will broadly impair healing should be balanced against the high risk of another fracture.⁵⁸

References

1. Compston JE, McClung MR, Leslie WD. Osteoporosis. Lancet. 2019;393(10169):364-376. doi:10.1016/S0140-6736(18)32112-3.
2. Morin SN, Leslie WD, Schousboe JT. Osteoporosis: a review. JAMA. 2025. doi:10.1001/jama.2025.6003.
3. Black DM, Geiger EJ, Eastell R, et al. Atypical femur fracture risk versus fragility fracture prevention with bisphosphonates. N Engl J Med. 2020;383(8):743-753. doi:10.1056/NEJMoa1916525.
4. Nayak S, Greenspan SL. A systematic review and meta-analysis of sequential treatment strategies for osteoporosis. Osteoporos Int. 2026. doi:10.1007/s00198-025-07717-5.
5. Chandran M, Akesson KE, Javaid MK, et al. Impact of osteoporosis and osteoporosis medications on fracture healing: a narrative review. Osteoporos Int. 2024;35(10):1725-1738. doi:10.1007/s00198-024-07059-8.
6. Bawa HS, Weick J, Dirschl DR. Anti-osteoporotic therapy after fragility fracture lowers rate of subsequent fracture: analysis of a large population sample. J Bone Joint Surg Am. 2015;97(19):1555-1562. doi:10.2106/JBJS.N.01275.
7. Queipo Menendez J, Garcia Tellado A, Pardo Lleidas J, Hernandez Hernandez JL. Hypercalcemia after denosumab discontinuation in patients with osteoporosis: a systematic review and case report. Osteoporos Int. 2026. doi:10.1007/s00198-026-07854-5. PMID:41571922.
8. Hesari E, Sanjari M, Mansourzadeh MJ, et al. Osteoporosis medication adherence tools: a systematic review. Osteoporos Int. 2023. doi:10.1007/s00198-023-06789-5. PMID:37286664.
9. Bandeira TFGS, Aguiar PM, Vianna CM, Mosegui GBG, Lima TDM. Romosozumab Versus Teriparatide for the Treatment of Postmenopausal Osteoporosis: An Overview of Systematic Reviews With Direct and Indirect Meta-Analyses. Int J Rheum Dis. 2026. doi:10.1111/1756-185X.70658. PMID:41999058.