Osteoporosis (cont.)

In choosing a medication for osteoporosis, a physician will consider all aspects of a patient's medical history as well as the severity of the osteoporosis.

If a postmenopausal woman has other menopausal symptoms such as hot flashes and vaginal dryness, HRT will be the proper choice for these menopausal symptoms as well as for the prevention of osteoporosis. After the menopausal symptoms have passed, some other non-estrogen prescription medication will be considered for the longer 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 well studied and effective category of prescription medication for treating postmenopausal osteoporosis.

A few serious esophageal conditions preclude the use of oral bisphosphonates, specifically esophageal stricture or achalasia. In these two conditions, it is likely that the bisphosphonate tablets will be retained in the esophagus and lead to esophageal inflammation, ulceration, and scarring. Caution often is advised for people with dysphagia (trouble swallowing) because the dysphagia may be a manifestation of a problem in the esophagus that will cause the bisphosphonate tablets to get stuck. Caution also is advised when there is gastritis, duodenitis, or ulcers because of the possibility that the bisphosphonate will aggravate the inflammation associated with these conditions. Any worsening of gastrointestinal symptoms should be reported immediately, but the vast majority of people tolerate bisphosphonates without symptoms when the prescribing directions are followed carefully. Fortunately, GERD or heartburn, which are common, are not reasons for withholding bisphosphonates. Prescribing directions should be followed carefully. Moreover, intravenous bisphosphonates, such as zoledronate (Reclast) or injectable denosumab (Prolia), may be given to those with esophageal strictures, achalasia, dysphagia, or gastrointestinal side effects from oral bisphosphonates.

In patients with GERD or who have symptoms of heartburn, risedronate may prove to cause less irritation to the esophagus than alendronate, but now intravenous bisphosphonates, such as zoledronate may be preferred.

Calcitonin is a weaker antiresorptive medication than bisphosphonates. It is reserved for patients who cannot take or will not consider taking other medications. Raloxifene also is a weaker medication for improving bone density or preventing fractures as compared to estrogen or bisphosphonates. In patients with moderate to severe osteoporosis, it is advisable to use the more potent antiresorptive medications (bisphosphonates). In addition, the safety and effectiveness of more than three years of raloxifene, or more than 24 months of teriparatide, have not been well studied.

Estrogen 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 estrogen replacement does. Both estrogen and raloxifene lower the "bad" LDL cholesterol.

Source: MedicineNet.com
http://www.medicinenet.com/osteoporosis/article.htm