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Aim: This paper determines the polymorphism distribution of the VDR BsmI gene in 350 patients and provides medication recommendations for osteoporosis based on detection results. Materials & methods: Chi-square tests compared genotype and allele frequencies with other populations. Results: Genotype frequencies were 91.66 bb, 8.72 Bb and 0.21% BB, with allelic frequencies of 95.43 b and 4.57% B, adhering to Hardy–Weinberg equilibrium. These findings suggest that VDR gene polymorphisms, particularly at the BsmIlocus, play an essential role in bone health and osteoporosis treatment. Genotype-based drug selection reduced adverse reactions from 14 to two cases. Conclusion: These findings improve clinical treatment efficacy and guide rational drug use for osteoporosis patients. Article highlights Objective To determine the polymorphism distribution of the vitamin D receptor (VDR) BsmI locus gene in osteoporosis patients and provide medication recommendations. Methods Genetic testing of 350 patients for VDR BsmI gene polymorphisms, comparison of genotype and allele frequencies, and assessment of the impact on drug selection. Significance Understanding the role of VDR gene polymorphisms in bone health and treatment response, and the potential for genotype-based drug selection. Results Genotype distribution: The study identified three genotypes at the BsmI locus: bb (91.66%), Bb (8.72%) and BB (0.21%), with allele frequencies of 95.43% for b and 4.57% for B. This distribution aligns with the Hardy–Weinberg equilibrium, indicating a representative sample. Comparison with other populations: The VDR gene allele frequencies in the Guangdong Han population significantly differ from those in South Asia, America, Europe and Africa but are similar to other East Asian populations. Impact on bone mineral density: There was no significant difference in bone mineral density T-scores before and after treatment across the different VDR genotypes, but patients with the b allele showed better responses to osteoporosis treatments, particularly with bisphosphonates. Adverse drug reactions (ADRs): before genetic testing, there were 14 ADRs, which reduced to only two cases post implementation, indicating improved treatment outcomes and reduced side effects through genotype-based drug selection. Conclusions The study supports the importance of genetic testing in guiding osteoporosis treatment as VDR gene polymorphisms, particularly at the BsmI locus, significantly influence treatment efficacy and the occurrence of ADRs. Genotype-based drug selection can improve clinical outcomes and minimize side effects. The findings suggest the need for further research on the distribution and impact of VDR BsmI locus polymorphism in different Chinese populations. Large-scale, multicenter studies are recommended to validate these results and enhance the precision of genotype-based drug recommendations. Integrating pharmacogenomics into clinical practice promises to improve the effectiveness of osteoporosis treatments, minimize adverse reactions, and advance personalized medicine, ultimately enhancing patient outcomes and quality of life. [ABSTRACT FROM AUTHOR]