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The economic, social and personal burdens of osteoporosis carry a heavy toll. Despite this, it is significantly under-recognized and under-treated. Complete evaluation includes work-up and recognition of secondary causes of osteoporosis in addition to biochemical marker and bone densitometry testing. Recognition of factors contributing to falls is a critical part of prevention of fragility fractures in the elderly. Nutraceutical treatments include calcium and vitamin D. Pharmacologic treatments include bisphosphonates, raloxifene, estrogen, testosterone, strontium ranelate, calcitonin and parathyroid hormone (recombinant 1–34 and 1–84). Although bisphosphonates are generally considered first-line therapy, therapies such as raloxifene and zoledronate have unique benefits. Nonpharmacologic interventions include weight-bearing exercise and behavioral counseling for modification of risk factors such as smoking and alcohol use. Fall and fracture prevention with hip protectors and balance training have also been used. The ideal duration of therapy is not well established. Treatment failure should raise concerns about compliance and secondary causes of fractures/osteoporosis.