Treating osteoporosis with denosumab or bisphosphonates in the long term: facts, uncertainties and assumptions. A narrative review by the clinical action group of the European Calcified Tissue Society (ECTS)

: Osteoporosis is a chronic disease that requires long-term management, particularly in high-risk patients who have a substantial increase in fracture risk. Antiresorptive medications remain the most widely used treatment for osteoporosis. This review aims to evaluate the available evidence on the long-term effects of bisphosphonates and denosumab, in order to help physicians determine the most suitable long-term management regimen for their patients, while balancing efficacy, safety, and fracture risk. Both bisphosphonates and denosumab have demonstrated efficacy in reducing fracture risk and increasing bone mineral density for up to 10 years. However, evidence to support their safety and efficacy beyond this period remains scarce. Given the increasing number of patients being treated with bisphosphonates or denosumab in the long term, we strongly advocate conducting observational follow-up studies in these patients. Currently, treatment decisions are based on personal experience and expert opinions, as well as discussions with the patient within a shared decision-making framework. We hope that this manuscript will give important background information for these discussions and facilitate final decisions.