Pharmaceutical treatments for osteoporosis

The latest pharmaceutical treatment approaches for osteoporosis were covered in a number of expert presentations at the Irish Osteoporosis Society 2026 Annual Medical Conference.

Dr Rosie Lannon, Consultant Geriatrician, Bone Health Unit, St James Hospital, Dublin, gave a detailed presentation on osteoporosis management using bisphosphonates.

She explained that bisphosphonates are the oldest specific medications for osteoporosis, “and when tolerated and persisted with they can be very effective. They are also suitable for treatment breaks.” She also discussed the risk of osteonecrosis of the jaw and atypical femoral fracture risk for patients on bisphosphonates, both of which are extremely rare, with the risks of bone breakages “far higher” if not on bisphosphonates.

Dr Donal Fitzpatrick, Consultant Geriatrician, St James’s Hospital, discussed the role of denosumab, a human monoclonal antibody for the treatment of bone loss in severe osteoporosis, administered via injection every six months. He noted its efficacy for bone mineral density (BMD) gains and bone breakage prevention, as well as its good safety data for long-term use.

However, half of new users in Ireland stop taking denosumab within two years, highlighting compliance issues and the need for careful patient selection, adequate information, support, and follow-up, he noted.

Denosumab discontinuation or late/missed injections causes rapid bone loss, with rebound even after one month, which increases the risk of multiple vertebral fractures particularly among those with existing vertebral fractures, Dr Fitzpatrick warned. The decision to stop denosumab therefore needs to be very carefully considered alongside an exit treatment plan. “There must be a compelling reason to stop,” he said, as once stopped even the addition of bisphosphonates, with up to three doses of zoledronic acid, may not prevent subsequent bone loss. “Treatment beyond 10 years is also no reason to stop,” Dr Fitzpatrick added.

The next speaker was Dr Kevin McCarroll, Consultant Physician and Geriatrician, Bone Health Unit, St James’s Hospital, who discussed romosozumab, a monoclonal antibody that targets sclerostin, a protein that inhibits bone formation and also promotes bone resorption. Romosozumab is unique in having both anabolic and antiresorptive effects, making it the most potent osteoporosis therapy for increasing BMD and reducing fracture risk developed to date, he explained. However, its use warrants caution in individuals with high cardiovascular risk.

Romosozumab therapy should be followed by an antiresorptive agent such as a bisphosphonate or denosumab, otherwise BMD gains can dissipate. One year of romosozumab followed by denosumab for 12 months results in improvements at the total hip and spine equivalent to nearly seven years of denosumab, Dr McCarroll said.

Ms Ciara Shields, Chartered Physiotherapist and Clinical Specialist in Musculoskeletal Physiotherapy, IONA Physiotherapy, Dublin, addressed the issue of opportunistic screening for osteoporosis.

She noted that BMD is an imperfect predictor of fracture risk, citing data showing that the majority of individuals with low trauma fracture do not have osteoporosis on DXA and some have no decreased BMD. While FRAX is a useful screening tool to help identify high-risk patients, it has limitations and does not measure balance, physical activity, falls, and strength.

‘FRAX plus’ addresses some of these limitations and includes diabetes risk too, but still does not adequately capture all those at risk of fracture and osteoporosis, Ms Shields maintained. “Muscle function and physical performance are not measured in BMD or FRAX and are known to be predictive of falls or fracture.” She discussed the benefits of gait speed (10MWT) and hand grip measurement as useful, easy to apply, investigative additions to enhance prediction, and encouraged clinicians to always take the opportunity to investigate osteoporosis risk in patients presenting with falls, frailty, and other known osteoporosis risks.

Also speaking during this session was Dr Richard Tobin, a GP in Mayo and International Society for Clinical Densitometry-certified practitioner, who discussed DXA assessment beyond BMD, specifically incorporating trabecular bone score (TBS). TBS is essentially a measure of bone texture correlated with bone microarchitecture and an independent marker for fracture risk in osteoporosis and is thus a useful risk calculation addition.