Table 2.

Pharmacological management of osteoporosis

Category	First-line therapy	Alternative first-line therapies
Young postmenopausal with only vertebral osteoporosis and history of or at high risk for breast cancer	Raloxifene Falling out of favor due to the presence of more effective and safer medications	Oral bisphosphonates IV bisphosphonates Denosumab Teriparatide
Older postmenopausal/or younger but with concerns of hip fracture	Oral bisphosphonates* Denosumab	IV bisphosphonate Teriparatide Romosozumab
Osteoporosis in men	Oral bisphosphonates* Denosumab	IV bisphosphonate Teriparatide
Severe osteoporosis Very low BMD T≤3.0 + one fracture or ≤2.5 + 2 fractures OR Imminent fracture risk (in the immediate post-fracture period)	Teriparatide Romosozumab	Oral bisphosphonates IV bisphosphonate Denosumab
Glucocorticoid-induced osteoporosis (GIOP)	Oral bisphosphonates IV bisphosphonate Denosumab Teriparatide

*Oral bisphosphonate (only alendronate or risedronate has evidence (Ia) for hip fracture efficacy), IV bisphosphonate (zoledronic acid). Alternative first line is considered if first line were not feasible, contraindicated, or failed. Can also be considered when therapy has to be discontinued but patient still requires treatment