Updates in Osteoporosis Medications: Maximizing Benefits and Minimizing Risks

Background Osteoporosis is a major public health concern affecting approximately 1 in 3 women and 1 in 5 men over the age of 50 globally. Hip fractures are a significant complication of osteoporosis and are associated with approximately 20-24% mortality in the year after fracture. While medications can substantially reduce fracture risk, these therapies remain significantly underutilized. This treatment gap is partly driven by confusion among healthcare professionals and patients regarding potential treatment complications. Findings This narrative review provides a practical overview of strategies to maximize benefits and minimize risks of pharmacologic osteoporosis therapies, including calcium/vitamin D, bisphosphonates, denosumab, parathyroid hormone (PTH) analogs, romosozumab, raloxifene, and menopausal hormone therapy (MHT). In addition to reviewing the latest data about therapeutic efficacy and safety, we provide a summary of best practices to mitigate potential side effects. Relevant updates include new data on the efficacy of bisphosphonates in lower risk patients, recommendations for using osteoanabolic agents as first-line for very high fracture risk patients, important considerations regarding multiple vertebral fractures when discontinuing denosumab, as well as cardiovascular safety data and the option of a shortened course for romosozumab. FDA updates are highlighted: removal of the osteosarcoma black-boxed warning for PTH analogs, nuances in the warnings regarding MHT, and addition of a black-boxed warning for severe hypocalcemia with denosumab in chronic kidney disease. Conclusion The benefits of osteoporosis medications in preventing high-morbidity fragility fractures significantly outweigh the small risks of serious complications. It is essential for clinicians to understand the myths and realities of these treatments and to implement mitigation strategies to ensure patient safety. By effectively addressing these issues, healthcare professionals can play a vital role in closing the osteoporosis treatment gap.