Osteoporosis: Treat to Target, Not Treat and Hope

The 2024 ASBMR and BHOF Task Force advocates a treat-to-target framework for osteoporosis management, using total hip bone mineral density T-score as the primary surrogate endpoint. For patients at imminent or very high fracture risk, initiating therapy with osteoanabolic agents prior to antiresorptive consolidation yields superior bone mineral density gains and fracture reduction compared to standard sequential bisphosphonates, which blunt subsequent anabolic efficacy. Clinicians must navigate denosumab discontinuation rebound through planned antiresorptive transitions, address insurance step therapy barriers, and leverage fracture liaison services to mitigate the alarming secondary prevention treatment gap following fragility fractures.