If an orthopedic surgeon is involved, consult with them for an appropriate time to start antiresorptive therapy. Otherwise, it is generally considered safe and effective to start 2 weeks post fracture.

• If the fracture is an atypical femur fracture, bisphosphonates should be stopped and held pending endocrinology review.

• For all other fractures, if an orthopedic surgeon is involved, consult with them for an appropriate time to start antiresorptive therapy. Otherwise, treatment can be continued. This is a time to evaluate whether a switch is needed therapy is needed. 

• In the event a patient cannot tolerate or the use of antiresorptive therapy is inappropriate, the JCEM 2019 guidelines non antiresorptive therapy based on age, VTE risk, breast cancer risk, and vasomotor symptoms with a selective estrogen receptor modulators (raloxifene, bazedoxifene), hormone therapy (estrogen or estrogen + progestin or tibolone), calcitonin, or calcium and vitamin D.
• In this situation or that of a man, we recommend consulting with endocrinology.

• The use of combination therapy has not shown to improve outcomes and is associated with increased cost, burden, and adverse events

• The exception is a study with two years of both denosumab and teriparatide. This is not general practice.

• There is no generally agreed upon definition. Antiresorptive therapy reduces the risk of fracture but does not eliminate it.
• JCEM 2019 defines treatment failure as “loss of BMD greater than the least significant change… over 2 years.  We would consider having two or more fractures while on therapy as treatment failure, especially vertebral fractures.  In clinical practice, the occurrence of one fracture while on effective therapy in a compliant patient will raise the consideration of changing therapy. In such cases, we suggest switching to one of the alternative therapies discussed in this guideline.
• Given the uncertainty, an endocrine consultation is suggested.