Osteoporosis Treatment Alternatives

First-Line Alternatives

The American College of Physicians strongly recommends zoledronic acid alongside alendronate, risedronate, and denosumab for reducing hip and vertebral fractures in women with known osteoporosis 1, 2
Zoledronic acid 5 mg IV once yearly eliminates daily GI exposure and is equally effective at reducing hip, vertebral, and nonvertebral fractures 1, 2
Risedronate 35 mg once weekly or 5 mg daily reduces hip, vertebral, and nonvertebral fractures with a similar efficacy profile to alendronate 1, 2
Denosumab 60 mg subcutaneously every 6 months reduces hip, vertebral, and nonvertebral fractures without GI exposure 1, 2

Ibandronate 150 mg once monthly reduces vertebral fractures but does NOT reduce hip or nonvertebral fractures 1
The American College of Physicians notes ibandronate's limited efficacy compared to other bisphosphonates 1
Teriparatide 20 mcg subcutaneously daily reduces vertebral and nonvertebral fractures but is reserved for very high-risk patients 1, 3

The American College of Physicians strongly recommends AGAINST raloxifene for osteoporosis treatment 1, 2
Raloxifene reduces only vertebral fractures, not hip or nonvertebral fractures 1
The American College of Physicians strongly recommends AGAINST menopausal estrogen therapy (with or without progestin) for osteoporosis treatment 1, 2

All patients starting any osteoporosis medication must receive calcium 1,000-1,200 mg daily 6, 4
All patients starting any osteoporosis medication must receive vitamin D 600-800 IU daily (some guidelines recommend 800-1,000 IU), with target serum 25(OH)D level ≥30 ng/mL 6, 4

Treat for 5 years initially, then reassess fracture risk to determine need for continued therapy 1, 2, 6
The American College of Physicians recommends against BMD monitoring during the initial 5-year treatment period 1, 2