Advances in anabolic therapies for osteoporosis

Irish Society for Rheumatology Autumn Meeting, Radisson Blu Hotel, Little Island, Cork, 18-19 September 2025

Dr Barbara Hauser, Consultant Rheumatologist, Western Regional Hospital, Edinburgh, Scotland, made a presentation at the Irish Society for Rheumatology Autumn Meeting titled ‘Anabolic therapies for osteoporosis: Recent advances and clinical experience’.

Dr Hauser covered four main areas during her talk: The mechanism of action in anabolic treatment; romosozumab trial data including cardiovascular risk; sequencing of anabolic treatment; and real-world data of anabolic treatment.

She began by explaining the rationale for giving anabolic therapy compared to antiresorptive therapy in severe osteoporosis, noting that antiresorptive therapy cannot reverse bone loss while anabolic therapy builds new bone. Anabolic therapy romosozumab is a monoclonal antibody that inhibits sclerostin and boosts bone formation, Dr Hauser outlined.

Dr Hauser presented data from a 2017 study published in the New England Journal of Medicine, which showed that romosozumab is superior to alendronate in severe spinal osteoporosis. The same article, featuring data from the ARCH study, looked at the incidence of serious adverse cardiovascular events.

It found more serious cardiovascular events in romosozumab patients in the 12-month group (2.5 per cent) than in the alendronate-only patient group (1.9 per cent).

A systematic review and meta-analysis of 25 randomised controlled trials published in 2025 found that romosozumab did not significantly increase the risk of cardiovascular events, mortality or adverse events compared to placebo and other anti-osteoporotic drugs. However, Dr Hauser cautioned the certainty of evidence was low to moderate due to study bias and imprecision.

The European Medicines Agency contraindicates romosozumab in patients with a history of myocardial infarction or stroke due to cardiovascular risk concerns.

Dr Hauser presented her own data from a centre in Scotland looking at romosozumab, noting patients on the drug had more severe osteoporosis at baseline. She concluded by stating that romosozumab is superior to alendronate in reducing vertebral and non-vertebral fractures in patients at high fracture risk.

Sequencing matters, she emphasised, as prior antiresorptive treatment can blunt responses to anabolic treatment.

She reiterated that romosozumab is contraindicated in patients with prior myocardial infarction or stroke and advised delegates on the importance of benefit/risk discussions when initiating treatment, as patients at high fracture risk frequently have high cardiovascular risk.