Table 2.

Advantages, adverse effects and contraindications of the main pharmacological interventions in osteoporosis

Treatment	Advantages	Side effects and contraindications	Guidance	Posology
Calcium and vitamin D	Reduce the risk of hip fracture and of total fracture Reduce rate of loss of BMD in the hip and spine Reduction in risk of falling Favourable effects on muscle health	Gastrointestinal symptoms Renal stones Some evidence suggests an increased risk of cardiovascular disease (including myocardial infarction) Contraindicated in pre-existing hypercalcaemia	Housebound older people or those living in a nursing home are advised to take 800 IU of vitamin D per day	1000 mg of calcium in combination with 400 IU of vitamin D, daily
Bisphosphonates	Reduce the risk of fractures amongst a broad age range of patients Increase BMD (lumbar spine; trochanter; femoral neck; total proximal femur) Reduce the risk of mortality when commenced after a fracture	Gastrointestinal symptoms Bone/muscle/joint pain Hypocalcaemia Osteonecrosis of the jaw (rare) Atypical femoral fractures (after 5 years of use) Issues with adherence Contraindicated in severe renal impairment; conditions impairing gastric emptying (achalasia, oesophageal stricture) and hypocalcaemia	For postmenopausal women and men over 50 years of age, who have been confirmed by DXA scan to have osteoporosis Ensure patients have normal serum calcium levels and are replete in vitamin D. Advise good dental hygiene and well-fitting dentures	Alendronate 10 mg PO, once daily or 70 mg once weekly Risedronate 5 mg PO, once daily or 35 mg PO, once weekly Ibandronic acid 150 mg PO, monthly (3 mg every 3 months IV) Zoledronic acid 5 mg IV annually
Denosumab	Reduce the risk of fractures (vertebral, hip, non-vertebral fractures) Increase in BMD without plateau	Hypocalcaemia (especially if impaired renal function) Increased risk of bacterial infections Skin rash Increase fracture risk back to pre-treatment level Osteonecrosis of the jaw (rare) Atypical femoral fractures Risk of severe hypocalcaemia especially with coexistent Vitamin D deficiency as well as renal impairment	Alongside calcium and vitamin D supplementation Alternative when oral bisphosphonates are not tolerated or are contraindicated Ensure patients have normal serum calcium levels and are replete in vitamin D. Advise good dental hygiene and well-fitting dentures	60 mg SC (6-montly)
Selective oestrogen receptor modulators	Reduction in both vertebral and non-vertebral fracture risk Appear to be safe to use in older people	Hot flushes; Lower limb cramps; Joint pain; Can increase risk of venous thromboembolism	Treatment and prevention of osteoporosis in post-menopausal women and are indicated after first line therapies have been considered	Raloxifene 60 mg, daily
Testosterone	Increase in BMD in men who are hypogonadal	Aggression; Prostate cancer; Psychiatric symptoms	For men at high risk for fracture with testosterone levels below 200 ng/dl (6.9 nmol/litre) and have contraindications to other osteoporosis’ therapies
Teriparatide	Appears to increase bone formation within 24 months of use	Nausea; Pain in limbs; Headache; Dizziness; Contraindicated in conditions with increased bone turnover (pre-existing hypercalcaemia, hyperparathyroidism, Paget’s disease); unexplained raised alkaline phosphatase and previous bone radiation therapy; malignancies with bony metastases and severe renal impairment	If intolerant or suffer severe side effects from first line therapies described	20 mcg SC daily (max. 24 months)
Abaloparatide	Lower risks of new vertebral fractures (compared teriparatide) Reduction in risk of nonvertebral Increase in BMD	Appears safe. Further drug safety data pending	Headache, nausea, dizziness, joint pain are key adverse effects	80 mcg SC daily
Romosozumab	Reduces the risk of vertebral and nonvertebral fractures	ARCH study reported an imbalance in serious cardiovascular adverse events. Use may be restricted	Joint pain, hypersensitivity reactions, hypocalcaemia are key adverse effects	210 mg (2 × 105 mg injections) SC monthly for 12 months

BMD bone mineral density, IU International Units, mg milligrams, DXA dual-energy X-ray absorptiometry, PO: per oral, IV: intravenous, SC subcutaneous