Abstract
Antiresorptive therapies are used to increase bone strength in individuals with osteoporosis and include five principal classes of agents: bisphosphonates, estrogens, selective estrogen receptor modulators (SERMs), calcitonin and monoclonal antibodies such as denosumab. However, no head-to-head studies have compared different antiresorptive agents using fracture as an end point. Bisphosphonates, which have proven antifracture efficacy and a good safety profile, are the most widely used first-line antiresorptive therapy and are recommended for patients with osteoporosis, a prior fragility fracture or osteopenia, as well as individuals with a high risk of fracture. Denosumab, which also has good antifracture efficacy, is another possible first-line therapy, although long-term safety data are lacking. However, no single antiresorptive therapy is currently appropriate for all patients or clearly superior to other therapies. Antiresorptive agents such as estrogens, SERMs (in postmenopausal women) and calcitonin are considered to be second-line agents that are appropriate in special circumstances. Clinicians should determine the most appropriate pharmacological therapy after a careful assessment of the risk:benefit profiles of these drugs in each patient. In addition, patients should receive a detailed explanation of the treatment goals, so that the therapeutic benefit can be maximized through good compliance and persistence.
Key Points
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Several antiresorptive agents can safely reduce fracture risk in various high-risk populations
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Bisphosphonates or denosumab should be recommended as first-line therapy for patients with osteoporosis
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Selective estrogen receptor modulators (SERMs) are currently not used as first-line therapy except, occasionally, in postmenopausal women aged <60 years who have a moderately increased fracture risk
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Short-term, low-dose estrogen treatment can be considered in newly postmenopausal women aged <60 years who also have menopausal symptoms
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Given its limited antifracture efficacy, calcitonin is only recommended in some circumstances, such as in patients who are unable to take other agents
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Selection of the most appropriate therapy for a specific patient should take into account relevant factors such as adverse effects, dosing regimen, cost and the patient's preference
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Chen, J., Sambrook, P. Antiresorptive therapies for osteoporosis: a clinical overview. Nat Rev Endocrinol 8, 81–91 (2012). https://doi.org/10.1038/nrendo.2011.146
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