Updated Guidelines on the Pharmacologic Treatment of Osteoporosis

Jessica Ganga

The American College of Physicians (ACP) Clinical Guidelines Committee updated its recommendations on the pharmacologic treatment of primary osteoporosis or low bone density to prevent fractures in adult patients.1 The last set of guidelines was published in 2017 and addressed the same topic.2

The ACP provided several recommendations for clinicians based on an updated systematic review of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

In the new guideline, the ACP strongly recommends, based on high-certainty evidence, the use of bisphosphonates—a group of medicines that slow bone loss and reduce the risk of hip and spine fractures—for initial pharmacologic treatment in postmenopausal women diagnosed with primary osteoporosis. Further, the ACP recommends the same treatment for men diagnosed with primary osteoporosis. In the 2017 guidelines, bisphosphonates were recommended but only for use in men.

In another change to the 2017 guidelines, the ACP now suggests the use of denosumab as a second-line pharmacologic treatment for men diagnosed with osteoporosis who have contraindications or experience adverse effects of bisphosphonates.

The additional recommendations include:

  • The use of romosozumab or teriparatide—followed by bisphosphonate—only in women who are at a high risk of fracture.
  • Clinicians taking an individualized approach when deciding to start treatment with bisphosphonate in women aged 65 or higher with low bone mass.



  1. Qaseem A, Hicks LA, Etxeandia-Ikobaltzeta I, Shamliyan T, Cooney TG. Pharmacologic treatment of primary osteoporosis or low bone mass to prevent fractures in adults: a living clinical guideline from the American College of Physicians. Ann Intern Med. Published online January 3, 2023. doi:10.7326/M22-1034
  2. Qaseem A, Forciea MA, McLean RM, Denberg TD. Treatment of low bone density or osteoporosis to prevent fractures in men and women: a clinical practice guideline update from the American College of Physicians. 2017;166:818-839. doi:10.7326/M15-1361