ACP 2023 living guideline: pharmacologic treatment of osteoporosis

Official guidelinePharmacologic Treatment of Primary Osteoporosis or Low Bone Mass to Prevent Fractures in Adults: A Living Clinical Guideline From the American College of Physicians. ACP, 2023.
Read the official guideline · Checked for a newer edition on 2026-10-20
We do not reproduce the guideline text — this page is an independent summary.

Who it applies to

Adults with primary osteoporosis or low bone mass (osteopenia) being considered for pharmacologic fracture prevention, primarily in primary care and outpatient settings.

Key recommendations

Bisphosphonates (alendronate, risedronate, zoledronic acid) are recommended as first-line therapy for most postmenopausal women with primary osteoporosis.
Denosumab is suggested as a second-line pharmacologic treatment for patients who have contraindications to or experience adverse effects from bisphosphonates.
In men with primary osteoporosis, bisphosphonates are also recommended as initial pharmacologic treatment.
Anabolic agents (teriparatide, abaloparatide, or romosozumab) followed by an antiresorptive agent are suggested for postmenopausal women at very high fracture risk.
Routine use of raloxifene or menopausal estrogen therapy for primary prevention of fractures is generally not recommended due to an unfavorable balance of benefits and harms compared with bisphosphonates.
Treatment duration with bisphosphonates should typically be considered for around 3 to 5 years, with reassessment of ongoing fracture risk before continuing or stopping.
In patients with low bone mass (osteopenia) rather than osteoporosis, pharmacologic treatment decisions should be individualized based on overall fracture risk rather than applied routinely.
Monitoring with routine serial bone mineral density testing during pharmacotherapy is not strongly supported as a basis for changing treatment decisions.

What is new in this edition

Reaffirms a living guideline format, allowing updates as new evidence on osteoporosis drugs emerges rather than a single static document.
Expanded and more explicit guidance on drug sequencing, including use of anabolic agents before antiresorptive therapy in very high-risk patients.

Practice points for students

Bisphosphonates remain the preferred first-line choice for both men and postmenopausal women with osteoporosis in most cases.
Denosumab is reserved as a second-line option when bisphosphonates are contraindicated or not tolerated.
Anabolic-to-antiresorptive sequencing (not the reverse) is the preferred strategy in very high-risk patients needing bone-building therapy.
Estrogen and raloxifene are not favored as primary fracture-prevention agents given their risk-benefit profile relative to bisphosphonates.
Osteopenia does not automatically warrant drug therapy; risk stratification should guide the decision.

Condition

Osteoporosis