From the Guidelines
Denosumab (Prolia) is recommended as a second-line pharmacologic treatment for postmenopausal females diagnosed with primary osteoporosis who have contraindications to bisphosphonates, due to its ability to reduce the risk of fractures. Medications for osteoporosis beyond bisphosphonates include several effective options.
- Denosumab, given as a subcutaneous injection every 6 months, is a monoclonal antibody that inhibits RANKL, reducing bone resorption 1.
- Selective estrogen receptor modulators (SERMs) like raloxifene (Evista) at 60mg daily can be used, particularly in postmenopausal women with increased risk of breast cancer.
- Teriparatide and abaloparatide are parathyroid hormone analogs administered as daily subcutaneous injections for up to 2 years, uniquely stimulating bone formation rather than just preventing resorption.
- Romosozumab (Evenity), given monthly for 12 months, is a sclerostin inhibitor that both increases bone formation and decreases resorption.
- Hormone replacement therapy (estrogen with or without progesterone) can be considered for postmenopausal women with vasomotor symptoms.
- Calcitonin nasal spray (200 IU daily) is less commonly used due to modest efficacy but may help with acute pain from vertebral fractures. These medications work through different mechanisms than bisphosphonates, providing alternatives for patients who cannot tolerate bisphosphonates or who have failed first-line therapy. The choice of medication should be based on patient preferences, fracture risk profile, and benefits, harms, and costs of medications, as suggested by the American College of Physicians guideline update 1.
From the FDA Drug Label
The efficacy and safety of Prolia in the treatment of patients with glucocorticoid-induced osteoporosis was assessed in the 12-month primary analysis of a 2-year, randomized, multicenter, double-blind, parallel-group, active-controlled study Treatment with Prolia significantly increased lumbar spine BMD compared to the active-control at one year The treatment differences in BMD at 1-year were 4.8% at the lumbar spine, 2.0% at the total hip, and 2.2% at femoral neck. Consistent effects on BMD were observed at the lumbar spine regardless of baseline age, race, BMD, testosterone concentrations, and level of bone turnover.
Medications for osteoporosis except bisphosphonates include:
- Denosumab (Prolia) Key points about denosumab:
- Increases bone mineral density (BMD) at the lumbar spine, total hip, and femoral neck
- Reduces bone turnover
- May cause serious infections, dermatologic adverse reactions, and musculoskeletal pain
- Requires transition to alternative antiresorptive therapy if discontinued 2 2
From the Research
Medications for Osteoporosis Except Bisphosphonates
- Estrogens: used to inhibit bone resorption, although through different mechanisms 3
- Selective estrogen receptor modulators (SERMs): such as raloxifene, can be used as an alternative for patients who cannot take bisphosphonates 3, 4, 5
- Calcitonin: can be used as an alternative for patients who cannot take bisphosphonates 3, 4, 5
- Denosumab: a monoclonal antibody that inhibits nuclear factor kB ligand, can be used as a first-line therapy, although long-term safety data are lacking 4, 5
- Teriparatide: a recombinant parathyroid hormone fragment, can increase bone mineral density and bone connectivity 5
Uses and Efficacy
- These medications can increase bone strength and reduce the risk of fractures in individuals with osteoporosis 4, 5
- They can be used to prevent and treat postmenopausal osteoporosis, and as alternatives for patients who cannot take bisphosphonates 5
- The choice of medication depends on the individual patient's risk-benefit profile and should be determined after a careful assessment by a clinician 4