What are the alternative treatment options for patients who cannot tolerate Fosamax (alendronate)?

Alternative Treatment Options for Patients Who Cannot Tolerate Fosamax (Alendronate)

For patients who cannot tolerate Fosamax (alendronate), alternative osteoporosis treatments include other bisphosphonates (risedronate, ibandronate, zoledronic acid), denosumab, raloxifene, teriparatide, or calcitonin, with selection based on patient characteristics, fracture risk, and specific intolerances. 1

First-Line Alternatives

Other Bisphosphonates

• Risedronate (Actonel): Available in multiple dosing options (5 mg daily, 35 mg weekly, 75 mg monthly for two consecutive days, or 150 mg monthly) 1
• Ibandronate (Boniva): Available as 150 mg monthly oral tablet or 3 mg IV every three months 1
• Zoledronic acid (Reclast): 5 mg IV infusion once yearly (for treatment) or every two years (for prevention) 1
  • Particularly useful for patients with gastrointestinal intolerance to oral bisphosphonates
  • Contraindicated in patients with creatinine clearance <35 mL/min 1

Non-Bisphosphonate Options

Denosumab (Prolia)

• RANK ligand inhibitor administered as 60 mg subcutaneous injection every six months 1
• Excellent option for patients with:
  • Gastrointestinal intolerance to oral bisphosphonates
  • Renal insufficiency (no dose adjustment needed) 2
  • High fracture risk 3

Raloxifene (Evista)

• Selective estrogen receptor modulator: 60 mg daily 1
• Best suited for younger postmenopausal women at higher risk for vertebral fractures than hip fractures 2
• Contraindicated in patients with history of venous thromboembolism 1

Second-Line Options

Teriparatide (Forteo)

• Recombinant parathyroid hormone: 20 mcg subcutaneous injection daily 1
• Reserved for patients with:
  • Severe osteoporosis
  • Previous osteoporotic fractures
  • Very high fracture risk 1, 3

Calcitonin (Miacalcin/Fortical)

• Available as nasal spray (200 IU daily) or injectable form (100 IU subcutaneous or intramuscular every other day) 1
• Consider only for patients with:
  • Less serious osteoporosis
  • Inability to tolerate other treatments
  • Need for pain relief from vertebral fractures 1, 4
• Has weaker efficacy data compared to other options 1

Selection Algorithm Based on Patient Factors

1. For patients with GI intolerance to oral bisphosphonates:

   • First choice: IV zoledronic acid or denosumab 2
   • Alternative: Raloxifene (especially in younger postmenopausal women) 1

2. For patients with renal insufficiency:

   • Denosumab (no renal adjustment needed) 2
   • Avoid zoledronic acid if creatinine clearance <35 mL/min 1

3. For patients with high fracture risk or previous fractures:

   • Denosumab or zoledronic acid (IV) 3
   • Consider teriparatide for severe cases 1, 3

4. For patients with compliance concerns:

   • Monthly ibandronate (preferred over weekly alendronate in patient preference studies) 5
   • Denosumab (twice-yearly injection) 1
   • Annual zoledronic acid infusion 1

Important Considerations

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

  • Calcium: 1000-1200 mg daily
  • Vitamin D: 800-1000 IU daily 3

• Lifestyle modifications remain essential:

  • Weight-bearing exercise
  • Smoking cessation
  • Limiting alcohol intake
  • Fall prevention strategies 1, 3

• Monitoring response:

  • DEXA scan should be performed 1-2 years after initiating therapy 3

Cautions and Contraindications

• Oral bisphosphonates require patients to remain upright for at least 30 minutes after administration 6
• IV bisphosphonates may be preferred if there are concerns about esophageal abnormalities 6
• All bisphosphonates carry risks of osteonecrosis of the jaw and atypical femur fractures with long-term use 6
• Raloxifene is contraindicated in patients with history of venous thromboembolism 1

Remember that treatment selection should prioritize reduction in fracture risk (morbidity and mortality) while considering the specific reason for Fosamax intolerance to avoid similar issues with alternative medications.