Choosing among drugs 

When pharmacologic treatment is to be given, clinicians should choose among options based on an assessment that balances risks and benefits for the individual patient, the Guidelines recommend. While diverse agents have been approved for osteoporosis prevention or treatment, they differ in efficacy (e.g., the types of fractures they have been shown to reduce) and in adverse-effect profile.

All things considered, the bisphosphonates are “reasonable options” for first-line therapy, the authors say. There is strong evidence that certain of these drugs reduce the incidence of vertebral, nonvertebral, and hip fracture, and they are a particularly apt choice when the risk of hip fracture is high. Although there are few head-to-head data to guide a choice among bisphosphonates, the authors observe that alendronate and risedronate have the best research support. Both drugs are FDA- approved for prevention and treatment of osteoporosis.

The most common side effects of bisphosphonate therapy  involve the upper GI tract. They are for the most part mild, although esophageal ulcerations, perforations, and bleeding events have been reported.

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The risk/benefit equation for other agents makes them less attractive choices overall than bisphosphonates, although patient factors and tolerability may argue in their favor in individual cases. Calcitonin is less efficacious than bisphosphonates—the evidence that it reduces vertebral fractures is weaker, and it appears not to reduce nonvertebral fractures—but it is apparently without serious side effects. Calcitonin has been approved by the FDA for treatment but not prevention of osteoporosis.

Estrogen, on the other hand, is supported by good evidence that it effectively reduces vertebral, nonvertebral, and hip fractures. But serious adverse-effect issues, particularly those involving thromboembolic events and cancer, limit its use. Estrogen is approved for prevention of osteoporosis but not for treatment.

Among selective estrogen receptor modulators, raloxifene is approved for both osteoporosis prevention and treatment. This drug, however, has only been shown effective against vertebral fractures, and pooled data suggest that it carries increased risk of thromboembolic and mild cardiac events.

Vitamin D and calcium

There is little evidence that calcium alone reduces fractures, while the data on vitamin D are more positive but mixed. A recent meta-analysis of 29 randomized controlled trials concluded that supplementation with both calcium and vitamin D reduces fractures by 13%. The Guidelines authors observe that most pharmacologic trials have included these supplements and recommend adding calcium and vitamin D to whatever treatment regimen is chosen.

Screening for Osteoporosis in Men: a Clinical Practice Guideline from the American College of Physicians was published in Annals of Internal Medicine (2008;148:680-684, accessed May 5, 2009). Pharmacological Treatment of Low Bone Density or Osteoporosis to Prevent Fractures: a Clinical Practice Guideline from the American College of Physicians was published in Annals of Internal Medicine (2008;149:404-415, accessed May 5, 2009). 

Mr. Sherman is a medical writer in New York City.