Medical therapy to prevent fractures in people with low bone density

25(OH)D: 25-hydroxyvitamin D; eGFR: estimated glomerular filtration rate; CKD: chronic kidney disease; GI: gastrointestinal; BMD: bone mineral density.
* Refer to additional UpToDate content on evaluation of hypercalcemia and hypocalcemia.
¶ Severe osteoporosis: T-score of ≤–3.0 even in the absence of fractures, T-score of ≤–2.5 plus a fragility fracture, severe or multiple vertebral fractures.
Δ If cost, subcutaneous administration, and long-term safety are not a concern, some experts prefer initial anabolic therapy, recognizing that follow-up therapy with an antiresorptive agent is indicated to maintain gains acquired with an anabolic agent.
◊ We generally prefer teriparatide or abaloparatide administered for 18 to 24 months. An acceptable alternative is romosozumab administered as 12 monthly doses.
§ Oral bisphosphonates are poorly absorbed and must be taken on an empty stomach first thing in the morning with at least 240 mL (8 oz) of water. After administration, the patient should not have food, drink, medications, or supplements and should remain upright for at least one half-hour.