Alendronate merck manual

Among those with more than eight years of alendronate use, the adjusted odds ratio decreased to 0. There was a dose-response relationship noted between longer effective alendronate use and a reduced risk for type 2 diabetes. More Information. All rights reserved. Common Health Topics. FOSAMAX should not be used in patients who have certain disorders of the esophagus that delay emptying, who are unable to stand or sit upright for at least 30 minutes, who have low levels of calcium in their blood, or in patients who are allergic to FOSAMAX.

Some patients may develop severe digestive reactions, including irritation, inflammation, or ulceration of the esophagus. Dosing instructions should be followed, and patients who experience new or worsening heartburn, difficulty or pain when swallowing, or chest pain should stop taking the drug and call their doctor right away.

The risk of ONJ may increase with duration of exposure to bisphosphonates. Atypical femur fractures have been reported in patients taking bisphosphonates. Through our prescription medicines, vaccines, biologic therapies, and consumer care and animal health products, we work with customers and operate in more than countries to deliver innovative health solutions.

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Unsubscribe from email alerts. We are committed to providing leading innovations for today and the future that save and improve lives around the world. Private Securities Litigation Reform Act of Long-term bisphosphonate use may increase the risk of atypical femoral fractures.

These fractures occur in the mid-shaft of the femur with minimal or no trauma and may be preceded by weeks or months of thigh pain. The fractures may be bilateral even if symptoms are only unilateral. To minimize fracture incidence, consideration should be given to stopping bisphosphonates a bisphosphonate holiday after about. Intermittent cessation of bisphosphonate treatment drug holiday , as well as initiation and duration of therapy, depend on patient risk factors such as age, comorbidities, prior fracture history, DXA scan results, and fall risk.

The drug holiday is 1 year or longer. Patients on a bisphosphonate holiday should be closely monitored for a new fracture or accelerated bone loss evident on a DXA scan, especially after being off therapy for 2 years or more. During therapy with an antiresorptive drug, such as a bisphosphonate, bone turnover is suppressed as evidenced by low fasting N-telopeptide cross-links Intranasal salmon calcitonin should not regularly be used for treating osteoporosis.

Salmon calcitonin may provide short-term analgesia after an acute fracture, such as a painful vertebral fracture, due to an endorphin effect. It has not been shown to reduce fractures. Estrogen can preserve bone mineral density and prevent fractures. Most effective if started within 4 to 6 years of menopause, estrogen is given orally and may slow bone loss and possibly reduce fractures even when started much later. Use of estrogen increases the risk of thromboembolism and endometrial cancer and may increase the risk of breast cancer.

The risk of endometrial cancer can be reduced in women with an intact uterus by taking a progestin with estrogen see Hormone therapy Hormone Therapy Menopause is physiologic or iatrogenic cessation of menses amenorrhea due to decreased ovarian function. Manifestations may include hot flushes, night sweats, sleep disruption, and genitourinary However, taking a combination of a progestin and estrogen increases the risk of breast cancer, coronary artery disease, stroke, and biliary disease.

Because of these concerns and the availability of other treatments for osteoporosis, the potential harms of estrogen treatment for osteoporosis treatment outweigh its potential benefits for most women; when treatment is initiated, a short course with close monitoring should be considered. Raloxifene is a selective estrogen receptor modulator SERM Selective estrogen receptor modulators SERMS Menopause is physiologic or iatrogenic cessation of menses amenorrhea due to decreased ovarian function.

Raloxifene does not stimulate the uterus and antagonizes estrogen effects in the breast. It has been shown to reduce the risk of invasive breast cancer. Raloxifene has been associated with an increased risk of thromboembolism. Denosumab is a monoclonal antibody against RANKL receptor activator of nuclear factor kappa-B ligand and reduces bone resorption by osteoclasts. Denosumab may be helpful in patients not tolerant of or unresponsive to other therapies or in patients with impaired renal function.

This drug has been found to have a good safety profile at 10 years of therapy. Denosumab is contraindicated in patients with hypocalcemia because it can cause calcium shifts that result in profound hypocalcemia and adverse effects such as tetany. Patients taking denosumab should not undergo a drug holiday because stopping this drug may cause a rapid loss in bone mineral density and, importantly, increase the risk of fractures, particularly vertebral fractures, sometimes multiple.

If and when denosumab is discontinued, transition to a bisphosphonate such as IV zoledronic acid should be considered for a year or more, depending upon ongoing risk of fracture.

Romosozumab is a monoclonal antibody against sclerostin a small protein made by osteocytes that inhibits new bone formation by osteoblasts. It has both antiresorptive and anabolic effects and has been shown to increase bone mineral density in the hip and lumbar spine and reduce fracture risk in postmenopausal women 2 Treatment references Osteoporosis is a progressive metabolic bone disease that decreases bone mineral density bone mass per unit volume , with deterioration of bone structure.

Romosozumab is indicated for patients with severe osteoporosis, particularly in older people, those who are frail, and those with an increased risk of falling.

It should also be considered in patients who fracture despite adequate antiresorptive therapy. It is given via monthly subcutaneous injection for 1 year 3 Treatment references Osteoporosis is a progressive metabolic bone disease that decreases bone mineral density bone mass per unit volume , with deterioration of bone structure. Romosozumab treatment for 1 year followed by alendronate for 1 year is more efficacious than treatment with alendronate for 2 years 3 Treatment references Osteoporosis is a progressive metabolic bone disease that decreases bone mineral density bone mass per unit volume , with deterioration of bone structure.

Romosozumab carries a black box warning due to increased risk for cardiovascular events, including myocardial infarction, stroke, and cardiovascular death. It should not be initiated within 12 months of a patient having had a myocardial infarction or stroke. As with denosumab , when romosozumab is discontinued, bisphosphonate therapy should be given to prevent rapid bone loss.

The immediate initiation of antiresorptive agent therapy after an osteoporotic fracture has been controversial because of a theoretical concern that these agents may impede bone healing. However, recent American Society of Bone and Mineral Research ASBMR treatment recommendations for secondary prevention of fractures include the recommendation to initiate an oral bisphosphonate during the hospitalization for the fracture 4 Treatment references Osteoporosis is a progressive metabolic bone disease that decreases bone mineral density bone mass per unit volume , with deterioration of bone structure.

Also, there is no reason to delay therapy in order to obtain a DXA scan because a hip or vertebral fragility fracture establishes the presence of osteoporosis. They are given daily by subcutaneous injection and increase bone mass, stimulate new bone formation, and reduce the risk of fractures. Romosozumab Preserving bone mass Osteoporosis is a progressive metabolic bone disease that decreases bone mineral density bone mass per unit volume , with deterioration of bone structure.

These three anabolic agents teriparatide , abaloparatide , and romosozumab are generally indicated for patients who have the following characteristics:. Fail to respond ie, develop new fractures or lose bone mineral density to antiresorptive drugs, as well as calcium, vitamin D, and exercise. Possibly have severe osteoporosis eg, T-score The use of anabolic agents to treat osteoporosis had been limited to 2 years based on a black box warning because of concern of increased risk of developing osteosarcoma Osteosarcoma osteogenic sarcoma Primary bone tumors are much less common than metastatic bone tumors, particularly in adults.

Primary bone tumors include multiple myeloma, osteosarcoma, adamantinoma, chondrosarcoma, chordoma Consequently, although 2 years of treatment with an anabolic agent remains a reasonable course of therapy, giving a second 2-year course of therapy can now be considered. However, after completion of a treatment course with an anabolic agent, the bone mineral density gains are quickly lost if a patient is not quickly transitioned to an antiresorptive agent such as a bisphosphonate Preserving bone mass Osteoporosis is a progressive metabolic bone disease that decreases bone mineral density bone mass per unit volume , with deterioration of bone structure.

Anabolic agents are safe to initiate at any time after a fracture. It is not clear whether early post-fracture use of anabolic agents accelerates bone healing. Many older patients are at risk of falls because of poor coordination and balance, poor vision, muscle weakness, confusion, and use of drugs that cause postural hypotension Causes of Orthostatic Hypotension Orthostatic postural hypotension is an excessive fall in blood pressure BP when an upright position is assumed. Core-strengthening exercises may increase stability.

Educating patients about the risks of falls and fractures, modifying the home environment for safety, and developing individualized programs to increase physical stability and attenuate risk are important for preventing fractures.

Acute back pain resulting from a vertebral compression fracture should be treated with orthopedic support, analgesics, and, when muscle spasm is prominent, moist heat Heat Treatment of pain and inflammation aims to facilitate movement and improve coordination of muscles and joints. Nondrug treatments include therapeutic exercise, heat, cold, electrical stimulation Core-strengthening exercises are helpful for patients who have back pain and a prior healed vertebral fracture.

Chronic backache may be relieved by exercises to strengthen paravertebral muscles. Avoiding heavy lifting can help. Bed rest should be minimized, and consistent, carefully designed weight-bearing exercise should be encouraged. In some patients, vertebroplasty or kyphoplasty can be used to relieve severe pain due to a new vertebral fragility fracture; however, the evidence for efficacy is inconclusive.

In vertebroplasty, methyl methacrylate is injected into the vertebral body. In kyphoplasty, the vertebral body is first expanded with a balloon then injected with methyl methacrylate. These procedures may reduce deformity in the injected vertebrae but do not reduce and may even increase the risk of fractures in adjacent vertebrae.

Other risks may include rib fractures, cement leakage, pulmonary embolism, or myocardial infarction. Further study to determine indications for these procedures is warranted.

J Bone Miner Res 27 2 : —, N Engl J Med 16 , N Engl J Med 15 , J Bone Miner Res , [Epub ahead of print]. The goals of prevention are 2-fold: preserve bone mass and prevent fractures.

Preventive measures are indicated for the following:. Preventive measures for all of these patients include appropriate calcium and vitamin D intake, weight-bearing exercise, fall prevention, and other ways to reduce risk eg, avoiding tobacco and limiting alcohol.

In addition, drug therapy is indicated for patients who have osteoporosis or who have osteopenia if they are at increased risk of fracture, such as those with a high FRAX score, and patients taking glucocorticoids.

Drug therapy tends to involve the same drugs as are given for treatment of osteoporosis. Educating patients and the community about the importance of bone health remains of utmost importance.

Bone is lost at a rate of about 0. Suspect osteoporosis in patients who have fractures caused by unexpectedly little force fragility fractures of the spine, humerus, distal radius, or hip. For treatment and prevention, ensure adequate intake of calcium and vitamin D, using supplements when necessary, and modify risk factors to help preserve bone mass eg, with weight-bearing exercise and by minimizing use of caffeine, alcohol, and tobacco.

Treatments include antiresorptive drugs eg, bisphosphonates, a selective estrogen receptor modulator, receptor activator of nuclear factor kappa-B ligand [RANKL] inhibitor, a drug used for hormone replacement therapy or an anabolic agent such as teriparatide , abaloparatide , or romosozumab.

The following English-language resources may be useful. American Association of Clinical Endocrinology AACE Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis, Update : Information for healthcare professionals and their patients about the diagnosis, evaluation, and treatment of postmenopausal osteoporosis. From developing new therapies that treat and prevent disease to helping people in need, we are committed to improving health and well-being around the world.

The Merck Manual was first published in as a service to the community. Learn more about our commitment to Global Medical Knowledge. This site complies with the HONcode standard for trustworthy health information: verify here. Common Health Topics. Videos Figures Images Quizzes Symptoms. Commonly Searched Drugs. Fragility fractures. Primary osteoporosis. Secondary osteoporosis. Risk Factors. Symptoms and Signs. Preserving bone mass Preventing fractures Treating pain and maintaining function Treatment references.

Key Points. More Information.