What is the first-line osteoporosis medication for a patient with a history of breast cancer: Evista (raloxifene), Fosamax (alendronate), or Forteo (teriparatide) or estrogen?

From the Guidelines

For a patient with a history of breast cancer needing first-line osteoporosis medication, Fosamax (alendronate) would be the recommended choice. Alendronate is typically prescribed at 70mg once weekly or 10mg daily and is considered safe and effective for breast cancer survivors 1. Evista (raloxifene) should be avoided as it's a selective estrogen receptor modulator that may pose theoretical risks in breast cancer patients despite its bone benefits, and the American College of Physicians recommends against using raloxifene for the treatment of osteoporosis in women 1. Forteo (teriparatide) is generally reserved as a second or third-line agent due to cost and is contraindicated in patients with high risk for osteosarcoma, as it was associated with osteosarcoma development in animal studies 1. Estrogen therapy is absolutely contraindicated in breast cancer survivors as it may stimulate cancer recurrence 1. Alendronate works by inhibiting osteoclast-mediated bone resorption without the hormonal effects that could potentially influence breast cancer cells. The patient should take alendronate with a full glass of water while remaining upright for 30-60 minutes afterward to prevent esophageal irritation. Some key points to consider when prescribing alendronate include:

• The recommended dosage is 70mg once weekly or 10mg daily 1
• Common side effects include upper GI irritation, myalgias, and arthralgias 1
• Calcium (1000-1200mg daily) and vitamin D (800-1000 IU daily) supplements should also be recommended as adjunctive therapy unless contraindicated 1 The American College of Physicians recommends offering pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab to reduce the risk for hip and vertebral fractures in women who have known osteoporosis, with a strong recommendation and high-quality evidence 1.

From the FDA Drug Label

Raloxifene hydrochloride is an estrogen agonist/antagonist indicated for: Treatment and prevention of osteoporosis in postmenopausal women. Raloxifene hydrochloride tablets are for women after menopause, and has more than one use: Osteoporosis: Raloxifene hydrochloride tablets treat and prevent osteoporosis by helping make your bones stronger and less likely to break Raloxifene hydrochloride tablets have not been fully studied in women who have a history of breast cancer.

The first-line osteoporosis medication for a patient with a history of breast cancer is not explicitly stated in the provided drug labels. However, based on the available information, Evista (raloxifene) may be considered, but with caution, as it has not been fully studied in women with a history of breast cancer 2, 2, 2. It is essential to weigh the potential benefits and risks of raloxifene treatment with the patient. Fosamax (alendronate) and Forteo (teriparatide) are not mentioned in the context of breast cancer history in the provided labels. Estrogen is not recommended due to potential risks. A conservative clinical decision would be to consult the patient's medical history and discuss the potential benefits and risks of each medication with the patient.

From the Research

First-Line Osteoporosis Medication for Breast Cancer Patients

The first-line osteoporosis medication for a patient with a history of breast cancer can be determined based on the available evidence.

• Alendronate (Fosamax) is a bisphosphonate that has been shown to be effective in increasing bone density and reducing the risk of fractures in postmenopausal women with osteoporosis 3, 4, 5.
• Raloxifene (Evista) is a selective estrogen receptor modulator (SERM) that has been shown to reduce the risk of vertebral fractures in postmenopausal women with osteoporosis, but its effects on nonvertebral fractures are not yet proven 4, 5.
• Teriparatide (Forteo) is an anabolic agent that stimulates new bone formation, but it is not typically considered a first-line treatment for osteoporosis 6.
• Estrogen therapy is usually contraindicated in women with a history of breast cancer due to the potential risk of stimulating cancer growth 4.

Treatment Considerations

When considering treatment options for osteoporosis in breast cancer patients, it is essential to weigh the benefits and risks of each medication.

• Alendronate has been shown to be effective in reducing the risk of vertebral and nonvertebral fractures in postmenopausal women with osteoporosis, making it a suitable first-line treatment option 3, 4, 5.
• Raloxifene may be considered as an alternative treatment option for patients who cannot tolerate alendronate or have contraindications to its use 4, 5.
• Teriparatide and estrogen therapy are not typically considered first-line treatment options for osteoporosis in breast cancer patients due to their potential risks and limitations 4, 6.