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Medical Author:

William C. Shiel Jr., MD, FACP, FACR

William C. Shiel Jr., MD, FACP, FACR

Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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Medical Editor:

Dennis Lee, MD

Dennis Lee, MD

Dr. Lee was born in Shanghai, China, and received his college and medical training in the United States. He is fluent in English and three Chinese dialects. He graduated with chemistry departmental honors from Harvey Mudd College. He was appointed president of AOA society at UCLA School of Medicine. He underwent internal medicine residency and gastroenterology fellowship training at Cedars Sinai Medical Center.

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Medical Editor:

Catherine Burt Driver, MD

Catherine Burt Driver, MD

Catherine Burt Driver, MD, is board certified in internal medicine and rheumatology by the American Board of Internal Medicine. Dr. Driver is a member of the American College of Rheumatology. She currently is in active practice in the field of rheumatology in Mission Viejo, Calif., where she is a partner in Mission Internal Medical Group.

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In this Article

• What is osteoporosis?
• What are osteoporosis symptoms and signs?
• What are the consequences of osteoporosis?
• Why is osteoporosis an important public health issue?
• What factors determine bone strength?
• What are osteoporosis risk factors and causes?
• How is osteoporosis diagnosed?
• Who should have bone density testing?
• What is the treatment for osteoporosis, and can osteoporosis be prevented?
• Exercise, quitting cigarettes, and curtailing alcohol
• Calcium supplements
• Vitamin D
• Hormone therapy (hormone replacement therapy, menopausal replacement therapy)
• Medications that prevent bone loss and breakdown
• Choosing an osteoporosis medication
• Prevention of osteoporosis caused by long-term corticosteroids
• Monitoring osteoporosis therapy medication
• Prevention of hip fractures in elderly people with osteoporosis
• Osteoporosis At A Glance
• Find a local Internist in your town

Choosing an osteoporosis medication

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 biphosphonate 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 biphosphonate tablets to get stuck. Caution also is advised when there is gastritis, duodenitis, or ulcers because of the possibility that the biphosphonate 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, gastroesophageal reflux disease (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) 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.