Bone is a common site of metastases, particularly in advanced breast and prostate cancer. Skeletal related events associated with bone metastases include pathologic fracture, need for surgery/radiation to bone and cord compression. These events cause significant morbidity and mortality. Bisphosphonates as well as denosumab act on the bone microenvironment and reduce the rate of skeletal related events by approximately 25%–40%. Hence, these therapies are an important adjunctive therapy in cancer care. Despite the established efficacy and recommendations for their use in many international guidelines, these bone modifying agents are underutilized. This review examines the currently available guidelines on bone modifying agents in metastatic bone disease and summarizes their efficacy, risk and comparative benefits.