What are the medications and dosages used to treat osteoporosis, including duration of treatment?

Treatment for Osteoporosis: Medications, Dosages, and Duration

First-line treatment for postmenopausal osteoporosis should be oral bisphosphonates—specifically alendronate 70 mg once weekly or risedronate 35 mg once weekly—continued for 5 years, with consideration for interruption after this period. 1

First-Line Therapy: Oral Bisphosphonates

Alendronate (Fosamax):

• Treatment dose: 70 mg once weekly OR 10 mg daily 1
• Prevention dose: 35 mg once weekly OR 5 mg daily 1
• Duration: 5 years, with reassessment for continuation 1
• Must be taken in the morning after overnight fast, 30 minutes before first food/beverage, with plain water only, while sitting or standing upright 1, 2

Risedronate (Actonel/Atelvia):

• Treatment dose: 35 mg once weekly OR 5 mg daily OR 150 mg once monthly 1
• Delayed-release formulation (Atelvia): 35 mg once weekly taken immediately after breakfast 3
• Duration: 5 years, with consideration for interruption after 5-10 years 1

Ibandronate (Boniva):

• Oral: 150 mg once monthly OR 2.5 mg daily 1
• Intravenous: 3 mg every 3 months 1
• Duration: Similar to other bisphosphonates, 5 years 1

Second-Line and Alternative Therapies

Zoledronic Acid (Reclast):

• Treatment dose: 5 mg IV once yearly 1
• Prevention dose: 5 mg IV every 2 years 1
• Duration: 5 years for treatment 1
• Contraindicated if creatinine clearance <35 mL/min/1.73 m² 1

Denosumab (Prolia):

• Dose: 60 mg subcutaneously every 6 months 1
• Duration: Ongoing as needed, but requires sequential bisphosphonate therapy upon discontinuation to prevent rebound vertebral fractures 1
• Particularly useful for high fracture risk patients 1

Raloxifene (Evista):

• Dose: 60 mg daily 1
• Best suited for younger postmenopausal women with lower fracture risk 1
• Reduces vertebral fractures but NOT hip fractures 1
• Not recommended due to increased risk of venous thromboembolism, stroke, and cardiovascular death 1

Anabolic Agents (Severe Osteoporosis)

Teriparatide (Forteo):

• Dose: 20 mcg subcutaneously daily 1
• Duration: Maximum 2 years lifetime use 1
• Reserved for severe osteoporosis, very high fracture risk, or treatment failure with bisphosphonates 1
• Should be followed by antiresorptive therapy to maintain gains 1

Abaloparatide:

• Similar dosing and indications to teriparatide 1
• Conditionally recommended for very high fracture risk 1

Treatment Duration and Monitoring

Duration Guidelines:

• Standard treatment: 5 years for bisphosphonates 1
• Trend toward interruption: After 5-10 years of bisphosphonate therapy, consider drug holiday based on reassessment 1
• Do NOT monitor BMD during the initial 5-year treatment period—it does not improve outcomes 1
• After 5 years, reassess fracture risk to determine if continuation is warranted 1

Special Populations

Men with Osteoporosis:

• Bisphosphonates (alendronate, risedronate, zoledronic acid) are recommended 1
• Dosing same as for postmenopausal women 1
• Evidence is weaker than for women (weak recommendation) 1

Glucocorticoid-Induced Osteoporosis:

• High/very high risk: Oral bisphosphonates strongly recommended 1
• Very high risk: PTH/PTHrP agents conditionally recommended over antiresorptives 1
• Moderate risk: Bisphosphonates, denosumab, or PTH/PTHrP in no preferred order 1

Essential Adjunctive Therapy

All patients should receive:

• Calcium: Age-appropriate dietary and supplemental intake 1
• Vitamin D: Optimized to resolve deficiency 1
• Take calcium supplements at different time than bisphosphonates to avoid interference 3

Critical Pitfalls to Avoid

• Do NOT use combination therapy—it is not recommended and provides no additional benefit 1
• Do NOT use hormone therapy (estrogen/progestogen) or raloxifene as first-line treatment due to cardiovascular and thromboembolic risks 1
• Do NOT use calcitonin except when patients cannot tolerate other options—it has weaker efficacy data 1
• Do NOT continue denosumab without planning sequential therapy—stopping causes rebound bone loss and vertebral fractures 1
• Do NOT prescribe bisphosphonates if creatinine clearance <35 mL/min (for zoledronic acid) or <30 mL/min (for oral bisphosphonates) 1