Choosing Among Osteoporosis Drugs

In choosing a medication for osteoporosis, a doctor will take into account all aspects of a patient's medical history and the severity of the osteoporosis.

If a postmenopausal woman has other menopausal symptoms such as hot flashes and vaginal dryness, menopausal hormone therapy will be the proper choice for these menopausal symptoms as well as for the prevention of osteoporosis. After the menopause symptoms have passed, some other non-estrogen prescription osteoporosis medication will be considered for the long-term.

If the prevention and treatment of osteoporosis is the only issue under consideration, then bisphosphonates such as alendronate, ibandronate, or risedronate are more effective than menopausal hormone therapy in preventing osteoporotic fractures, and less likely to be associated with substantial adverse effects. So far, bisphosphonates are the most effective category or prescription medications for treating postmenopausal osteoporosis.

A few specific serious esophageal conditions preclude the use of bisphosphonates. These are called esophageal stricture or achalasia. Caution is often advised for people with dysphagia, gastritis, duodenitis, or ulcers who take bisphosphonates. Any worsening symptom should be reported immediately, but the vast majority of people can tolerate bisphosphonates when the prescribing directions are followed carefully. Fortunately, gastroesophageal reflux disease (GERD) or heartburn, which are common, are not specific contraindications to the use of bisphosphonates. Prescribing directions should be followed carefully.

In patients with GERD or who have symptoms of heartburn, risedronate may prove to cause less irritation to the esophagus than alendronate.

Calcitonin is a weaker anti-resorptive medication than estrogenic bisphosphonates. It is reserved for those who cannot take or will not consider taking the other medications. Raloxifene is also a weaker medication (in improving bone density or preventing fractures) compared to estrogen or bisphosphonates (alendronate (Fosamax), ibandronate (Boniva), and risedronate (Actonel)). Thus, in patients with moderate to severe osteoporosis, it is advisable to use the more potent anti-resorptive medications. The safety and effectiveness of more than 3 years of raloxifene use or more than 24 months of teriparatide use, have not been well-researched.

Estrogen replacement and raloxifene differ in their side effects and also in their effects on cholesterol panels. For example, raloxifene does not raise the "good HDL cholesterol," but estrogen replacement does. They both lower the "bad LDL cholesterol."