What are the alternatives to Fosamax (alendronate) for women with osteoporosis?

Alternatives to Fosamax (Alendronate) for Women with Osteoporosis

For women with osteoporosis who cannot take or prefer alternatives to Fosamax (alendronate), risedronate, zoledronic acid, and denosumab are the recommended first-line alternatives with strong evidence for reducing fracture risk. 1

First-Line Alternatives to Alendronate

Bisphosphonate Alternatives

1. Risedronate (Actonel)

   • Dosing: 5 mg daily, 35 mg weekly, 75 mg on two consecutive days monthly, or 150 mg monthly 1
   • Efficacy: Reduces vertebral fractures and hip fractures 1
   • Administration: Take with plain water while upright, remain upright for 30 minutes 2

2. Zoledronic Acid (Reclast)

   • Dosing: 5 mg IV once yearly for treatment, every two years for prevention 1
   • Efficacy: Reduces vertebral, nonvertebral, and hip fractures 1
   • Advantage: Eliminates concerns about oral absorption and compliance with once-yearly dosing

3. Ibandronate (Boniva)

   • Dosing: 150 mg monthly oral or 3 mg IV every three months 1
   • Note: Less evidence for hip fracture reduction compared to other bisphosphonates

Non-Bisphosphonate Alternative

1. Denosumab (Prolia)
   • Mechanism: RANK ligand inhibitor (different from bisphosphonates)
   • Efficacy: Reduces vertebral, nonvertebral, and hip fractures 1
   • Particularly good option for women with high fracture risk or renal impairment 1

Second-Line Alternatives

1. Teriparatide (Forteo)

   • Anabolic agent (builds new bone rather than just preventing resorption)
   • Typically reserved for women with severe osteoporosis or who have had fractures 1
   • Limited to 2 years of therapy due to safety concerns

2. Calcitonin

   • Weaker evidence for fracture reduction
   • Should only be considered when women cannot tolerate other treatments 1

Not Recommended as First-Line Therapy

Raloxifene (Evista) and other estrogen receptor modulators:

• The American College of Physicians strongly recommends against using raloxifene for osteoporosis treatment 1
• Associated with increased risk of thromboembolic events, pulmonary embolism, and hot flashes 1
• May be considered in younger postmenopausal women with low risk of deep vein thrombosis 1

Estrogen therapy:

• Not recommended specifically for osteoporosis treatment 1
• Associated with increased risk of breast cancer, cardiovascular events, and thromboembolic events

Treatment Selection Algorithm

1. First determine contraindications to alendronate:

   • Esophageal abnormalities
   • Inability to remain upright for 30 minutes
   • Severe renal impairment
   • History of upper GI issues with bisphosphonates

2. If other bisphosphonates are suitable:

   • Choose risedronate for patients needing flexible dosing options
   • Choose zoledronic acid for patients with compliance concerns or GI intolerance

3. If bisphosphonates are contraindicated:

   • Denosumab is the preferred alternative, especially with renal impairment
   • Teriparatide for very high-risk patients with severe osteoporosis

Important Considerations for All Treatments

• Calcium and vitamin D supplementation should accompany all osteoporosis treatments:

  • Women 51-70 years: 1,200 mg calcium, 600 IU vitamin D daily
  • Women >70 years: 1,200 mg calcium, 800 IU vitamin D daily 1, 3

• Treatment duration is typically 5 years for most therapies, after which continuation should be reassessed 1, 3

• Monitoring: Bone density monitoring is not recommended during the initial 5-year treatment period 1

Common Pitfalls to Avoid

1. Inadequate calcium/vitamin D supplementation - essential with all osteoporosis medications
2. Poor administration technique with oral bisphosphonates - must be taken with plain water, while upright
3. Inappropriate monitoring - frequent BMD testing during treatment is not recommended
4. Failing to consider renal function when selecting therapy - denosumab preferred with renal impairment
5. Not recognizing rare but serious side effects like osteonecrosis of the jaw and atypical femoral fractures with long-term bisphosphonate use 3

By following this evidence-based approach to selecting alternatives to alendronate, clinicians can effectively manage osteoporosis while considering individual patient factors and preferences.