Table 5:

Medications for the treatment of osteoporosis^*

Drug	Route and dosing	Potential adverse effects	Contraindications	Other considerations	Cost†
Antiresorptive agents
Bisphosphonates
Alendronate	Oral: 70 mg weekly or 10 mg daily	Esophageal or GI intolerance MSK discomfort Rare: AFF, ONJ	CrCl < 30–35 mL/min Esophageal abnormalities Inability to be upright > 30 min Hypocalcemia	Foods, drinks (except plain water), other drugs should be avoided for > 30–60 min Minerals and dairy impair absorption if taken close together	$
Risedronate	Oral: 35 mg weekly or1 150 mg monthly or 5 mg daily	Esophageal/GI intolerance MSK discomfort Rare: AFF, ONJ	CrCl < 30–35 mL/min Esophageal abnormalities Inability to be upright > 30 min Hypocalcemia	Foods, drinks (except plain water), other drugs should be avoided for > 30–60 min Minerals and dairy impair absorption if taken close together Delayed-release formulation available (taken with food)	$
Zoledronic acid	Intravenous: 5 mg yearly	Transient flu-like symptoms Hypocalcemia Renal toxicity Rare: AFF, ONJ	CrCl < 35 mL/min Hypocalcemia	Inadequate vitamin D increases risk for hypocalcemia Less frequent dosing than yearly may be considered	$$
RANK-ligand inhibitor (monoclonal antibody)
Denosumab	Subcutaneous: 60 mg every 6 mo	Hypocalcemia Dermatitis, infections MSK discomfort Rare: AFF, ONJ	Hypocalcemia	Inadequate vitamin D increases risk for hypocalcemia Caution warranted in severe renal impairment Rapid bone loss and risk of vertebral fractures if delayed dose or with discontinuation	$$$
Hormonal therapy
Menopausal hormonal therapy	Multiple regimens	VTE, CVD, stroke Breast cancer	VTE, CVD, stroke, estrogen-dependent tumours, abnormal vaginal bleeding, active liver disease	Only in postmenopausal women	$–$$
Raloxifene (SERM)	Oral: 60 mg daily	VTE, CVD, stroke Vasomotor symptoms, leg cramps	VTE, CVD, stroke, abnormal vaginal bleeding	Only in postmenopausal women	$
Anabolic agents
Parathyroid hormone analog
Teriparatide	Subcutaneous: 20 μg daily for 24 mo	Orthostatic hypotension, nausea Hypercalcemia, hypercalciuria MSK discomfort	CrCl < 30 mL/min Bone malignancy, Paget disease, previous skeletal radiation Hypercalcemia disorder Unexplained elevated ALP	Caution warranted with active or previous kidney stone disease	$$$$$
Sclerostin inhibitor (monoclonal antibody)
Romosozumab	Subcutaneous: 210 mg monthly for 12 mo	Myocardial infarction, stroke Hypocalcemia MSK discomfort Rare: AFF, ONJ	Previous myocardial infarction or stroke Hypocalcemia	Inadequate vitamin D increases risk for hypocalcemia Caution warranted in severe renal impairment	$$$$$

Note: AFF = atypical femoral fracture, ALP = alkaline phosphatase, CrCl = creatinine clearance, CVD = cardiovascular disease, GI = gastrointestinal, MSK = musculoskeletal, ONJ = osteonecrosis of the jaw, RANK = receptor activator of nuclear factor κ-β, SERM = selective estrogen receptor modulator, VTE = venous thromboembolism.

^*Information in this table is not meant to be exhaustive and should not replace complete details provided by drug monographs (available in the Compendium of Pharmaceuticals and Specialties at myrxtx.ca). Further information on some medications available in selected references.^{15,43,46–51}

^†Relative cost.