What is a good medication to start an elderly female patient with osteoporosis and a current fracture on?

Recommended Treatment for Elderly Female with Osteoporosis and Current Fracture

Start this patient on a bisphosphonate—specifically alendronate 70 mg once weekly or risedronate 35 mg once weekly—as first-line therapy, as these agents have the strongest evidence for reducing both vertebral and hip fractures in postmenopausal women with established osteoporosis. 1

First-Line Pharmacologic Treatment

The American College of Physicians provides a strong recommendation (high-quality evidence) that clinicians offer bisphosphonates (alendronate, risedronate, or zoledronic acid) or denosumab to reduce hip and vertebral fracture risk in women with known osteoporosis. 1 However, bisphosphonates should be prioritized over denosumab as initial therapy due to their:

• Superior cost-effectiveness with available generic formulations 1
• Extensive evidence base showing 50% reduction in hip fractures and 47-56% reduction in vertebral fractures over 3 years 1, 2
• Favorable benefit-to-harm ratio compared to other agents 1
• No rebound fracture risk upon discontinuation, unlike denosumab 3, 4

Specific Bisphosphonate Options

Oral bisphosphonates:

• Alendronate 70 mg once weekly (preferred for convenience and equivalent efficacy to daily dosing) 4, 5
• Risedronate 35 mg once weekly 4

Intravenous option:

• Zoledronic acid (annual infusion) if oral administration is not feasible 1

Essential Concurrent Interventions

All patients require supplementation regardless of pharmacologic choice:

• Calcium 1,200 mg daily 1, 3, 4
• Vitamin D 800 IU daily (target serum level ≥20 ng/mL) 1, 3, 4
• Weight-bearing exercise (walking, dancing) 1, 4
• Fall prevention strategies including home safety assessment 1
• Smoking cessation and alcohol limitation 1, 4

Treatment Duration and Monitoring

• Initial treatment duration: 5 years 1, 3, 4
• Do NOT monitor bone density during the initial 5-year period—this provides no clinical benefit 1, 3
• After 5 years, reassess fracture risk to determine if continuation is warranted 1, 3, 4

Administration Instructions to Minimize Adverse Effects

To reduce gastrointestinal side effects and maximize absorption:

• Take on an empty stomach first thing in the morning 2
• Remain upright (sitting or standing) for at least 30 minutes after administration 2
• Take with a full glass of plain water only 2
• Wait at least 30 minutes before eating, drinking, or taking other medications 2

Safety Considerations and Monitoring

Common short-term adverse effects:

• Upper GI symptoms (abdominal pain, nausea, dyspepsia) are generally mild and transient 1, 4
• Influenza-like symptoms (particularly with zoledronic acid) 1

Rare long-term adverse effects (with prolonged use >5 years):

• Atypical femoral fractures 1
• Osteonecrosis of the jaw 1

These rare complications have higher risk after longer treatment duration, supporting the recommendation to reassess after 5 years. 1

When to Consider Alternative Agents

Reserve denosumab as second-line therapy for patients who:

• Have contraindications to bisphosphonates (severe renal impairment, esophageal disorders) 1
• Experience intolerable adverse effects from bisphosphonates 1
• Cannot comply with bisphosphonate administration requirements 1

Consider anabolic agents (teriparatide, abaloparatide, romosozumab) only for very high-risk patients:

• Recent vertebral fractures 1, 6
• Multiple fractures despite bisphosphonate therapy 1, 6
• T-score ≤-3.5 with additional risk factors 6

Note that teriparatide has a boxed warning for osteosarcoma risk (based on rat studies) and should be limited to 2 years lifetime use. 7 If anabolic agents are used, patients must transition to an antiresorptive agent afterward to prevent rebound bone loss. 1, 3

Critical Pitfalls to Avoid

• Never skip calcium and vitamin D supplementation—pharmacologic therapy is significantly less effective without adequate supplementation 3, 4
• Do not use denosumab as first-line when bisphosphonates are appropriate, as it is more expensive and carries rebound fracture risk upon discontinuation 1, 3, 4
• If denosumab is ever discontinued, immediately transition to a bisphosphonate to prevent multiple vertebral fractures from rebound bone turnover 1, 3, 4
• Ensure proper administration technique for oral bisphosphonates to minimize esophageal complications 4, 2
• Avoid raloxifene and menopausal hormone therapy—these have unfavorable risk-benefit profiles for osteoporosis treatment 1

Special Considerations for Elderly Patients

In elderly patients with multiple comorbidities:

• Assess medication adherence capacity before selecting oral bisphosphonates with complex administration requirements 1
• Consider annual IV zoledronic acid if adherence to oral medications is problematic 1
• Evaluate polypharmacy and drug interactions that may increase fall risk 1
• Screen for conditions that may worsen with bisphosphonates (severe GERD, esophageal stricture, inability to remain upright) 1, 2