For a patient who would benefit from an anabolic agent for osteoporosis, do you prefer romosuzumab over teriparatide in the absence of contraindications to either agent?

Both teriparatide and romozosumab are excellent drugs to treat osteoporosis with documented risk reduction in fractures. TPTD reduces spine fracture about 85% and romozosumab about 75%. Both are excellent.

They have very different biologies with TPTD being a remodeling-based anabolic and romozosumab predominantly a modeling-based anabolic. This is likely not real important clinically for the treatment of OP and trying to reduce fractures since they both work well. However, there is a difference for fracture healing. TPTD has an abundance of experience and literature that supports it may enhance fracture healing. Romozosumab actually has two negative studies for fracture healing.

If my main intent is the reduction of future fractures it ofte...

I agree with @Dr. First Last, once the decision to use an anabolic has been made insurance becomes the determining factor. For commercial insurance, they will generally approve a PTH agent over Romo. For Medicare Romo is generally more affordable if they are not on and Advantage plan. If they are even if approved it will be over $500 per month. We actively counsel our patients to avoid Advantage plans if possible when signing up for Medicare. Some companies do have financial assistance programs for PTH products for patients on Medicare.

Agree that the costs/insurance coverage, the patient's preference for daily injectable guides my treatment plan. I encourage and try to do PTH analog followed by sclerostin inhibitor if the patient and insurance agreeable.