Should anabolic therapy for osteoporosis be used as first line therapy? Anabolic agents stimulate bone formation whereas anti-resorptive agents reduce bone remodelling. Australian guidelines recommend the use of an anti-resorptive agent such as bisphosphonates or denosumab as first line therapy. However, the anabolic agents teriparatide (recombinant human parathyroid hormone 1-34), and the more recently available romosozumab (anti-sclerostin antibody), result in significant reduction in fracture risk compared to bisphosphonates therapy alone. Sustained fracture risk reduction after treatment with anabolic therapy can be achieved by consolidating bone mass accrued using subsequent anti-resorptive therapy. While current Australian treatment guidelines require prior treatment with anti-resorptive therapy, emerging data suggest the potential benefit of using anabolic agents as first-line treatment in those identified with high to very high fracture risk. Such protocols generally require subsequent anti-resorptive agent. Different combinations and sequential modalities have been studied with positive outcomes. Stratification of patients’ baseline absolute fracture risk, and identifying those with high fracture risk, could potentially lead to improved long term outcomes. In this talk, evidence on the role of osteoanabolic therapy in osteoporosis, and possible new models of therapy, will be discussed.