In which osteoporosis patients would you consider starting with anabolic therapy over antiresorptive therapy?

Anabolic therapies including teriparatide (PTH-analog), abaloparatide (PTHrP-analog), and romosozumab (anti-sclerostin) are all indicated for patients with osteoporosis and high fracture risk. Although denosumab (anti-RANKL) is an antiresorptive agent, it also leads to significant bone gain similar to an anabolic agent. 

Appropriate patients include those with one or more fragility fractures and a T score of < or = to -2.5 or a T score of < or = to -3.5 without a prior fracture. These treatments require anti-resorptive agents such as a bisphosphonate or denosumab after discontinuation to prevent rapid loss of bone and early fracture.  

Contraindications to teriparatide and abaloparatide include growing skeletons, a history of bone cancer, a history of radiation involving bones, Paget's disease, hypercalcemia, and pregnancy or nursing women.

Romosozumab is FDA approved for severe osteoporosis T<-3.5 or T<-2.5 with a prior fracture and unable to tolerate other medications because it is associated with an increase in myocardial infarction, stroke, or cardiovascular death.