Table 4:

Pharmacologic interventions for postmenopausal females and males aged 50 years and older for whom anti-osteoporosis treatment is recommended or suggested*

RecommendationsStrength of recommendation and certainty of evidence†
4. Pharmacologic interventions
4.1. Before initiating pharmacotherapy, good practice includes assessing for secondary causes of osteoporosis, and for potential limitations when considering specific osteoporosis pharmacotherapy.‡Good practice statement
4.2. When uncertainty exists about fracture risk or treatment, such as possible secondary causes of osteoporosis, comorbidities that complicate management and important adverse effects from pharmacotherapy, good practice includes seeking advice from a consultant with expertise in osteoporosis (e.g., family physician, general internist, endocrinologist, rheumatologist, geriatrician).Good practice statement
4.3. For people who meet criteria for initiation of pharmacotherapy, we recommend bisphosphonates (alendronate, risedronate or zoledronic acid).
Remark: Oral bisphosphonates may be preferred, as drug coverage, costs and access to an infusion centre may be barriers to zoledronic acid.		Strong recommendation; high-certainty evidence (females), moderate-certainty evidence (males)
4.4. For postmenopausal females aged < 60 yr or within 10 yr of menopause initiating pharmacotherapy who prioritize alleviation of substantial menopausal symptoms, we suggest menopausal hormone therapy as an alternative option to bisphosphonate therapy.
Remark: The choice will also depend on individualized risks of menopausal hormone therapy, which consists of an estrogen dose equivalent of conjugated equine estrogens of 0.625 mg daily (plus progestogen in those with an intact uterus).		Conditional recommendation; moderate-certainty evidence
4.5. For people meeting criteria for initiation of pharmacotherapy who have contraindications, substantial intolerance or barriers to bisphosphonates, we suggest denosumab.
Remark: Despite the benefits of denosumab, a careful assessment of indications is required because of the risk of rapid bone loss and vertebral fractures with delayed dosing or discontinuation of denosumab. It is important to communicate the need for commitment to long-term therapy and the need to transition to alternative antiresorptive therapy if discontinuing denosumab. Denosumab may be preferred when there is a high burden of oral medications, gastrointestinal intolerance, contraindication to oral bisphosphonates or barriers to accessing intravenous zoledronic acid.		Conditional recommendation; high-certainty evidence (females), moderate-certainty evidence (males)
4.6. For people meeting criteria for initiation of pharmacotherapy who have had a recent severe vertebral fracture, or > 1 vertebral fracture, AND a T-score ≤ −2.5, we suggest seeking advice from a consultant with expertise in osteoporosis about anabolic therapy (teriparatide or romosozumab).
Remark: “Recent fracture” is defined as a fracture occurring within the past 2 yr, and “severe vertebral fracture” as vertebral body height loss of > 40%. Clinicians may seek advice from radiologists to clarify the degree of severity of the vertebral fracture. The choice of anabolic therapy may depend on affordability and feasibility of injection schedule.		Conditional recommendation; high-certainty evidence (females), moderate-certainty evidence (males)
4.7. For postmenopausal females initiating pharmacotherapy who have contraindications or substantial intolerance to, or who choose not to take other suggested therapies, we suggest raloxifene rather than no treatment.
Remark: Raloxifene should be used only in those who are not at high risk of venous thromboembolism.		Conditional recommendation; moderate-certainty evidence