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Currently, bone-forming (anabolic) agents, in many countries, are used in those patients who have continued to lose bone mineral density (BMD), patients with multiple subsequent fractures or those who have fractured despite treatment with antiresorptive agents. However, head-to-head data suggest that anabolic agents have greater rapidity and efficacy for fracture risk reduction than do antiresorptive therapies. The European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) convened an expert working group to discuss the tools available to identify patients at high risk of fracture, review the evidence for the use of anabolic agents as the initial intervention in patients at highest risk of fracture and consider the sequence of therapy following their use. This position paper sets out the findings of the group and the consequent recommendations. The key conclusion is that the current evidence base supports an \u201canabolic first\u201d approach in patients found to be at very high risk of fracture, followed by maintenance therapy using an antiresorptive agent, and with the subsequent need for antiosteoporosis therapy addressed over a lifetime horizon.<\/jats:p>","DOI":"10.1007\/s40520-022-02100-4","type":"journal-article","created":{"date-parts":[[2022,3,25]],"date-time":"2022-03-25T02:02:21Z","timestamp":1648173741000},"page":"695-714","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":110,"title":["Management of patients at very high risk of osteoporotic fractures through sequential treatments"],"prefix":"10.1007","volume":"34","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5147-0550","authenticated-orcid":false,"given":"Elizabeth M.","family":"Curtis","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6290-752X","authenticated-orcid":false,"given":"Jean-Yves","family":"Reginster","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5472-1725","authenticated-orcid":false,"given":"Nasser","family":"Al-Daghri","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6174-1951","authenticated-orcid":false,"given":"Emmanuel","family":"Biver","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8741-0592","authenticated-orcid":false,"given":"Maria Luisa","family":"Brandi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0947-2226","authenticated-orcid":false,"given":"Etienne","family":"Cavalier","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4787-3151","authenticated-orcid":false,"given":"Peyman","family":"Hadji","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Philippe","family":"Halbout","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8194-2512","authenticated-orcid":false,"given":"Nicholas C.","family":"Harvey","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4274-9258","authenticated-orcid":false,"given":"Micka\u00ebl","family":"Hiligsmann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7985-0048","authenticated-orcid":false,"given":"M. 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N.A.D. reports no conflict of interest. E.B. reports lecture fees from Amgen, outside the submitted work. M.L.B. reports honoraria from Amgen, Bruno Farmaceutici, Calcilytix, Kyowa Kirin, UCB, grants or speaker fees from Abiogen, Alexion, Amgen, Bruno Farmaceutici, Echolight, Eli Lilly, Kyowa Kirin, SPA, Theramex, UCB and consulting fees from Aboca, Alexion, Amolyt, Bruno Farmaceutici, Calcilytix, Kyowa Kirin, UCB, outside the submitted work. E.C. EC is consultant for DiaSorin, IDS, Fujirebio and Nittobo. P.Hadji. reports personal fees, consultancy, lecture fees and honoraria from AMGEN, Eli Lilly, Fresenius, Gedeon Richter, Hexal, MSD, Novartis, Roche, Stada, Theramex, UCB, outside the submitted work. P. Halbout reports no conflict of interest. N.C.H. reports personal fees, consultancy, lecture fees and honoraria from Alliance for Better Bone Health, AMGEN, MSD, Eli Lilly, UCB, Kyowa Kirin, Servier, Shire, Consilient Healthcare and Internis Pharma, outside the submitted work. MKJ reports personal fees from Amgen, UCB and Besin Healthcare institutional grant support from Amgen and UCB outside of the submitted work. M.H. has received research grants through institution from Amgen, Radius Health, BD, ViiV Healthcare, lecture fees from Teva and Mylan, and consulting fees from UCB outside the submitted work. M.K.J. reports no conflict of interest. J.A.K.: Nothing to declare. JAK is the architect of FRAX\u00ae but has no financial interest. J-M.K. reports no conflict of interest in relation to the submitted work. O.L. reports no conflict of interest. R.M. reports no conflict of interest. A.D-P. reports lecture fees from Eli Lilly, Amgen and Gedeon Richter outside the submitted work. R.P.R.: Nothing to declare for the submitted work. M.R. reports no conflict of interest in relation to the submitted work. T.T. has received consultancy\/speaker\u2019s fees from Amgen, Arrow, Biogen, Chugai, Expanscience, Grunenthal, Jansen, LCA, Lilly, MSD, Nordic, Novartis, Pfizer, Sanofi, Thuasne, Theramex, TEVA et UCB and financial support or fees for research activities from: Bone Therapeutics, Chugai, UCB. F.T. reports personal fees, consultancy, lecture fees and honoraria from AMGEN, Fresenius, Gedeon-Richter, Hexal, HOLOGIC, Kyowa-Kirin, Stadapharm, Theramex, UCB, outside the submitted work. M.V. reports no conflict of interest in relation to the submitted work. J.Y.R. has received fees for lectures or advisory boards from IBSA-Genevrier, Mylan, Radius Health, Pierre Fabre, Faes Pharma, Rejuvinate Biomed, Teva, Theramex, Pfizer, Mithra Pharmaceuticals, CNIEL, Dairy Research Council, Nutricia, Danone and Agnovos, and industry grants (all through institution) from IBSA-Genevrier, Mylan, CNIEL, Radius Health and TRB, outside the submitted work. R.R. has received fees for lectures or advisory boards from Abiogen, Amgen, Danone, Echolight, European Milk Forum, Mithra, Nestl\u00e9, ObsEva, Pfizer Consumer Health, Radius Health, Rejunevate and Theramex. C.C. reports personal fees from ABBH, Amgen, Eli Lilly, GSK, Medtronic, Merck, Novartis, Pfizer, Roche, Servier and Takeda, outside the submitted work.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}},{"value":"This narrative article contains no original data and thus issues of ethics, informed consent and patient confidentiality do not apply.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}}]}}