Should osteoporosis medications be used in combination?
No, not yet. Combining antiresorptive medications should be avoided because of concern about excessively suppressing bone remodeling. Combining anabolic and antiresorptive medications is an appealing notion with emerging clinical trial data. The combination of teriparatide and alendronate had no synergy and resulted in inferior bone mass increases compared with teriparatide alone. In contrast, teriparatide combined with zoledronic acid or with denosumab did show synergy in regard to improvements in bone density. Despite these promising results, combination therapy is not currently recommended because there is no data showing superior fracture reduction compared with monotherapy. Furthermore, the cost of using combinations is certainly additive and may cause significant problems with insurance coverage. While combination therapy is not recommended, sequential therapy is clearly beneficial in many patients and is supported by a strong evidence base. Leaders in the field suggest that patients with severe osteoporosis may have maximal benefit by receiving anabolic therapy first, followed by an antiresorptive agent.