Osteoporosis Guidelines Updated: What Every Clinician Needs to Know in 2025
Osteoporosis Treatment Just Shifted: What Clinicians Need to Know Now
If you treat adults over 50, you know the numbers: 1 in 5 women has osteoporosis, and for most, the diagnosis comes after the first fracture. Those fractures change everything — mobility, independence, even life expectancy.
The American College of Physicians (ACP) has updated its Living Clinical Guideline on the pharmacologic treatment of primary osteoporosis and low bone mass. The update isn’t subtle; it reshapes the treatment ladder most clinicians have followed for years.
At Oakstone CME, we’ve spent decades helping physicians make sense of evolving evidence. Here’s what’s changed, and why it matters:
Bisphosphonates Take the Lead in Osteoporosis Treatment
In 2017, ACP said clinicians could start with either bisphosphonates or denosumab. The 2023 update removes the ambiguity: Bisphosphonates are now the clear first-line choice.
Why the shift? Three simple reasons:
- Proven fracture protection
- Strong safety and cost profile
- Broad generic availability
As Dr. Kashif Piracha — Internal Medicine Clerkship Director at Texas A&M and one of Oakstone’s featured experts — puts it:
“All drug courses end in bisphosphonate therapy.”
— Kashif Piracha, MD, FACP, Internal Medicine Clerkship Director, Texas A&M College of Medicine
That’s not a tagline; it’s the reality: no matter where patients start, bisphosphonates anchor long-term management.
Denosumab Takes a Step Back
Denosumab still has a role — it’s just not first-line anymore. ACP now positions it as second-line therapy, for patients who can’t tolerate bisphosphonates or have contraindications.
It’s still effective. But cost, the need for twice-yearly administration, and the risk of rebound fractures after discontinuation were enough to move it down the ladder.
What About High-Risk Patients?
For those at very high risk of fracture — older age, prior fractures, chronic steroid use — ACP recommends short-term use of anabolic agents like romosozumab or teriparatide, followed by a bisphosphonate.
Romosozumab can deliver impressive bone density gains, but with caveats: cardiovascular risk, cost, and a 12-month treatment cap.
The takeaway? Every choice comes with tradeoffs.
A Global Split: Not Everyone Agrees
Step outside the U.S. and you’ll find different playbooks.
- Canada and UK integrate FRAX scoring into treatment decisions and even consider HRT for younger postmenopausal women.
- ACP focuses squarely on pharmacologic therapy and fracture prevention.
The science isn’t static — it’s evolving. The ACP’s “living guideline” means updates every six months as new data surface.
Why This Matters for Everyday Practice
If you’re in internal medicine, rheumatology, or primary care, this isn’t theoretical. It’s about what you prescribe next week — and how you explain those choices to patients.
At Oakstone CME, our mission is simple: help you keep pace with change.
We break down the data, distill the decisions, and deliver it in ways that let you earn CME credit while you learn.
Get the Full Guideline Breakdown
Our free white paper, The Clinician’s Guide to ACP’s Living Osteoporosis Guideline, goes deeper — covering treatment sequences, global comparisons, and expert commentary from Dr. Piracha and Dr. Katherine Wysham.
[Download the Free White Paper]
Stay Current. Stay Credible. Earn CME.
Guidelines will keep changing.
Your patients — and your practice — deserve the latest thinking.
Oakstone CME gives you the tools to stay informed, apply evidence, and earn CME credit while doing it.
Bottom Line
Bisphosphonates are back on top. Denosumab moves to second. The conversation about cost, safety, and long-term management just got sharper, and Oakstone CME is here to help you stay ahead of it.