The role of anabolic agents

Antiresorptive and osteoanabolic agents constitute the two major classes of antiosteoporotic medication. Antiresorptive agents are most commonly used for postmenopausal, male, and glucocorticoid-induced osteoporosis. Osteoanabolic agents, which promote bone formation by activation of osteoblasts, are used as a second-line therapeutic modality, mainly for patients with severe osteoporosis and high fracture risk, unresponsive to antiresorptive compounds. The only osteoanabolic agents for the treatment of osteoporosis approved by the U.S. Food and Drug Administration (FDA) are teriparatide, a parathyroid hormone (PTH) synthetic analogue, and abaloparatide, a PTH-related peptide synthetic analogue. Both are administered as daily subcutaneous injections and may reduce the incidence of vertebral and nonvertebral fractures. They are generally well tolerated, with headache and nausea being the most common side effects. A third agent, which is characterized by a dual mechanism of action, is romosozumab—a humanized monoclonal antibody against sclerostin. It is effective in reducing vertebral and nonvertebral fracture risk. So far, it is under evaluation by the FDA, given concerns regarding an increased risk of cardiovascular disease events. The optimal sequence of administration of antiosteoporotic agents remains a matter of debate. A common strategy needing further proof is to administer antiresorptive agents after osteoanabolic ones to consolidate bone mineral density gains. Antiresorptive and osteoanabolic agents constitute the two major classes of antiosteoporotic medication. A common strategy needing further proof is to administer antiresorptive agents after osteoanabolic ones to consolidate bone mineral density gains. Osteoanabolic agents are mostly advocated as a second-line antiosteoporotic treatment, given their substantial cost. The sequence of administration of anabolic and antiresorptive agents determines the impact of skeletal response. Osteoanabolic agents are used as second-line drugs for the treatment of osteoporosis in patients with severe osteoporosis and high fracture risk, unresponsive to antiresorptive compounds. In general, osteoanabolic agents should always be followed by administration of an antiresorptive agent, such as bisphosphonates or denosumab, the latter having a greater effect. Osteoanabolic compounds stimulate and promote bone formation by activation of osteoblasts and bone remodeling. They are usually used as a second-line treatment