Selecting Appropriate Pharmacotherapy for Patients with Osteoporosis: Holistic Risk—Benefit Analysis

Abstract

In the US, the major pharmacotherapeutic approaches for the prevention or treatment of osteoporosis in women are estrogen-based hormone replacement therapy, selective estrogen receptor modulators, salmon calcitonin, bisphosphonates, calcium, and vitamin D. All of these treatments are beneficial in increasing bone mineral density and reducing fractures in patients with osteoporosis. However, each of the therapies possesses a unique mechanism of action and other potential benefits and side effects. Estrogen replacement therapy may lower the risk of cardiovascular disease, but it increases the risk of venous thromboembolism (VTE) and may increase the risk of breast cancer. Unopposed estrogen therapy is associated with increased risk for endometrial cancer, but the addition of progestins virtually eliminates this adverse event. The selective estrogen receptor modulator raloxifene is associated with positive cardiovascular effects and demonstrates a protective effect against some types of breast cancer. Like estrogen, raloxifene increases the risk of VTE. Salmon calcitonin has a strong analgesic effect and is not associated with any serious long-term adverse events, but some individuals may not be able to tolerate the nasal formulation. Bisphosphonates are associated with serious upper GI effects. The concomitant administration of calcium and vitamin D in all patients being treated for osteoporosis is generally recommended.

Selecting optimal treatment relies on an individualized risk–benefit analysis that takes into account the patient's medical history, concomitant diseases, current medications, general physical and mental well being, and personal feelings about the various therapies. Careful consideration of the various treatment options may lead to improved compliance and more effective management of osteoporosis.