Choosing between osteoporosis drugs

In choosing a medication for osteoporosis, a doctor will take into account all aspects of a patient's medical history, the severity of the osteoporosis and guidance from the National Institute for Health and Clinical Excellence (NICE).

If a postmenopausal woman has other menopausal symptoms, such as hot flushes and vaginal dryness, menopausal hormone therapy can be considered for these menopausal symptoms as well as for the prevention of osteoporosis. The Committee on the Safety of Medicines has advised that hormone replacement therapy (HRT) should not be considered first line therapy for long term prevention of osteoporosis in women over 50 years of age. HRT is of most benefit for the prophylaxis of postmenopausal osteoporosis if started early in menopause and continued for up to 5 years, but bone loss resumes (possibly at an accelerated rate) on stopping HRT. After the menopause symptoms have passed, some other non-oestrogen 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, risedronate or etidronate 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 oesophageal conditions preclude the use of bisphosphonates. These are called oesophageal stricture or achalasia. Caution is often advised for people with dysphagia, gastritis, duodenitise 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, gastro-oesophageal reflux disease (GORD) or heartburn, which are common, are not specific contraindications to the use of bisphosphonates. Prescribing directions should be followed carefully.

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

Calcitonin is a weaker anti-resorptive medication than 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 oestrogen or bisphosphonates and is reserved for those who cannot take or will not consider taking biphosphonates. Therefore, 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 three years of raloxifene use or more than 24 months of teriparatide use, have not been well-researched.

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