Choice of drug therapy for osteoporosis
For information about when to use drug therapy for osteoporosis, see Management of osteoporosis following minimal-trauma fracture and Management of osteoporosis in the absence of fracture. See also Considerations before treating osteoporosis.
For treatment of osteoporosis, the most commonly used drugs are antiresorptive drugs (ie an oral or intravenous bisphosphonate, or denosumab). The choice of antiresorptive drug is guided by comorbidities, patient preference and potential adverse effects. See Considerations to guide choice of antiresorptive drugs for osteoporosis for considerations to guide antiresorptive drug choice.
Treatment of premenopausal women and young patients (eg younger than 50 years) usually requires specialist input; an oral bisphosphonate is often favoured.
Use of teriparatide or romosozumab is limited by strict Pharmaceutical Benefits Scheme (PBS) funding criteria; they are usually reserved as second-line treatment for patients who experience a fracture while on antiresorptive therapy.
Hormone therapy can be useful in some women with osteoporosis. Estrogen and tibolone can be considered in postmenopausal women younger than 60 years, particularly those who have another indication for hormone therapy (eg menopausal symptoms). Raloxifene can be considered in young postmenopausal women with spinal osteoporosis, particularly if they have risk factors for breast cancer.
For patients with a secondary cause of osteoporosis, osteoporosis in women of child-bearing potential and pregnant women, post-transplant osteoporosis, and patients with osteoporosis and chronic kidney disease (particularly creatinine clearance less than 35 mL/min), seek specialist advice to guide management.
For current information about drugs for osteoporosis listed on the PBS, see the PBS website.
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Advantages |
Disadvantages |
|---|---|
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oral dosing low cost |
can cause or exacerbate upper gastrointestinal tract irritation absorption reduced by food, antacids, calcium, magnesium and iron requires more frequent dosing than intravenous options not recommended in severe kidney disease |
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oral dosing low cost enteric-coated formulation available (may have a lower incidence of gastrointestinal adverse effects, and absorption less affected by food, antacids, calcium, magnesium and iron) |
can cause or exacerbate upper gastrointestinal tract irritation absorption reduced by food, antacids, calcium, magnesium and iron requires more frequent dosing than intravenous options not recommended in severe kidney disease enteric-coated formulation only available as a weekly dose (non–enteric-coated formulation available as a monthly dose) |
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intravenous administration avoids gastrointestinal adverse effects yearly dosing can improve adherence |
intravenous administration not acceptable to some patients not recommended in severe kidney disease can cause transient influenza-like symptoms can cause uveitis (uncommon) can cause hypocalcaemia (particularly in patients with impaired kidney function [estimated glomerular filtration rate less than 35 mL/min/1.73 m2], vitamin D deficiency or a malabsorption disorder) |
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subcutaneous administration avoids gastrointestinal adverse effects dose adjustment not required in kidney disease 6-monthly dosing can improve compliance |
subcutaneous dosing not acceptable to some patients adherence to 6-monthly dosing regimen is essential to prevent loss of bone mineral density between doses therapy must be either indefinite, or replaced by a bisphosphonate if stopped withdrawal or interruption of treatment (dose delayed by more than 4 weeks) is associated with an increased risk of multiple spontaneous vertebral fracture can cause hypocalcaemia (particularly in patients with impaired kidney function [creatinine clearance 30 mL/min or less], vitamin D deficiency or a malabsorption disorder) |