Bisphosphonate Treatment Recommendations for Postmenopausal Osteoporosis

New recommendations provide guidance on prescribing bisphosphonates for patients with postmenopausal osteoporosis.

Among patients with postmenopausal osteoporosis, bisphosphonates should be administered as the first-line pharmacologic treatment, according to recommendations published in JAMA.

According to the guidelines, physicians should initiate pharmacologic therapy in postmenopausal women with osteoporosis who have a hip or spine bone mineral density (BMD) ≤-2.5 or a personal history of fragility fracture.

Researchers recommended an initial treatment of alendronate 70 mg/week or risedronate 35 mg/week or 150 mg/month. As an optional initial treatment, physicians should consider intravenous (IV) zoledronate (5 mg every 12 months) to eliminate the risk for adverse gastrointestinal (GI) effects and to ensure treatment adherence.

Related Articles

There are several common obstacles of using oral bisphosphonates. For GI intolerance, the researchers recommended emphasizing adherence to dosage instructions and considering the use of IV zoledronate. If a patient has impaired kidney function, they should not receive oral or IV bisphosphonates if creatine clearance is <30 to 35 mL/min. Among patients with poor treatment adherence, physicians should consider the use of IV zoledronate.

If there are concerns about serious harm caused by oral bisphosphonates, the researchers recommended considering patient oral health before bisphosphonate initiation. In addition, physicians can limit initial treatment period to no more than 5 years, reassessing whether to reinitiate treatment 2 to 3 years after initial discontinuation.

Alternative antiresorptive medications are available for patients with contraindications or intolerance to bisphosphonates. Subcutaneous denosumab (60 mg every 6 months) can reduce vertebral and nonvertebral fractures, and it can be used if creatinine clearance is <30 to 35 mL/min; however, it has a high cost and requires injections every 6 months. Potential risks include osteonecrosis of the jaw, atypical femoral fractures, rebound vertebral fractures upon discontinuation, and hypocalcemia.

Another alternative is oral raloxifene (60 mg daily), which reduces vertebral fractures and reduces the risk for breast cancer in high-risk women; however, it does not reduce nonvertebral or hip fractures and carries a risk for venous thromboembolic events.

“Due to their efficacy in fracture prevention, availability of long-term safety data, and cost advantage over several other agents, bisphosphonates remain the first-line pharmacologic treatment for postmenopausal osteoporosis,” the researchers wrote.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Ensrud KE, Crandall CJ. Bisphosphonates for postmenopausal osteoporosis [published online October 17, 2019]. JAMA. doi:10.1001/jama.2019.15781