Molecular structure pattern

Osteoporosis Drug Summary

Last updated: 29 September 2025
Reviewed by

Agents Affecting Bone Metabolism

Drug Dosage Remarks
Bisphosphonates1
Alendronic acid
(Alendronate) 		Prevention of postmenopausal osteoporosis: 5 mg PO 24 hourly or
35 mg PO once weekly or
70 mg PO once weekly
Treatment of postmenopausal osteoporosis and osteoporosis in men: 10 mg PO 24 hourly or
70 mg PO once weekly
Treatment and prevention of GIOP in men and estrogen-repleted women (eg premenopausal women or postmenopausal women with HRT):
5 mg PO 24 hourly
Treatment and prevention of GIOP in estrogen-deficient women (eg postmenopausal women without HRT):
10 mg PO 24 hourly 		Adverse Reactions
  • Upper GI effects (GI discomfort, esophagitis, esophageal ulcers); Other effects (rashes [occasionally with photosensitivity], transient and mild hypocalcemia or hypophosphatemia, severe bone, joint and/or muscle pain)
Special Instructions
  • For treatment of GIOP, continue treatment as long as glucocorticoid is administered
  • Avoid in patients with severe renal impairment (CrCl <35 mL/min)
  • Use with caution in patients with upper GI problems
  • Discontinue drug if patient develops dysphagia, odynophagia, retrosternal pain or new or worsening heartburn
  • There is a US FDA notice that bisphosphonates, approved to treat osteoporosis, are associated with possible risk of atypical subtrochanteric and diaphyseal femur fractures
  • Consider periodic reevaluation of the need for continued bisphosphonate therapy especially in patients who have been treated for >5 years
  • Administer with plain water ≥30 minutes before first food, beverage or medication of the day to enhance absorption
    • In an upright position, swallow the tablet whole; do not chew, crush or suck
    • Do not lie down or ingest any food, liquid or drugs for ≥30 minutes following administration to facilitate drug delivery to stomach and to avoid esophageal irritation
    • Do not administer at bedtime or before arising for the day
  • Calcium and Vitamin D supplementation is recommended if inadequate dietary intake. Separate administration from Alendronic acid by a few hours
Alendronic acid
(Alendronate)/Colecalciferol2 		Available dose:
Alendronic acid 70 mg/Colecalciferol 2,800 IU tab
Alendronic acid 70 mg/Colecalciferol 5,600 IU tab
Treatment of postmenopausal osteoporosis and osteoporosis in men where Vitamin D supplementation is recommended:
Alendronic acid 70 mg/Colecalciferol 2,800-5,600 IU PO once weekly
Ibandronic acid
(Ibandronate) 		Prevention and treatment of postmenopausal osteoporosis:
2.5 mg PO 24 hourly or
150 mg PO once monthly
Treatment of postmenopausal osteoporosis:
3 mg IV injection over 15-30 seconds every 3 months		 Adverse Reactions
  • GI effects (dyspepsia, abdominal pain, diarrhea, nausea/vomiting, gastritis, esophagitis, esophageal ulcerations); Other effects (back pain, headache, myalgia, cramps, arthralgia, bone pain)
Special Instructions
  • Avoid in patients with severe renal impairment
  • There is a US FDA notice that bisphosphonates, approved to treat osteoporosis, are associated with possible risk of atypical subtrochanteric and diaphyseal femur fractures
  • Consider periodic re-evaluation of the need for continued bisphosphonate therapy especially in patients who have been treated for >5 years
  • Administer with plain water 60 minutes before first food, beverage or medication of the day
    • In an upright position, swallow the tablet whole; do not chew, crush or suck
    • Do not lie down for 60 minutes following administration to facilitate drug delivery to stomach and to avoid esophageal irritation
  • Calcium and Vitamin D supplementation is recommended if inadequate dietary intake
Risedronic acid
(Risedronate) 		Prevention and treatment of postmenopausal osteoporosis:
5 mg PO 24 hourly or
35 mg PO once weekly or
75 mg PO taken on 2 consecutive days/month or
150 mg PO once monthly
Treatment of osteoporosis in men:
35 mg PO once weekly
Prevention and treatment of GIOP:
5 mg PO 24 hourly 		Adverse Reactions
  • Upper GI effects (abdominal discomfort, esophagitis, esophageal ulcers); Other effects (headache, severe bone, joint and/or muscle pain)
Special Instructions
  • Avoid in patients with severe renal impairment
  • For treatment of GIOP, continue treatment as long as glucocorticoid is administered
  • There is a US FDA notice that bisphosphonates, approved to treat osteoporosis, are associated with possible risk of atypical subtrochanteric and diaphyseal femur fractures
  • Consider periodic re-evaluation of the need for continued bisphosphonate therapy especially in patients who have been treated for >5 years
  • Administer with plain water ≥30 minutes before first food, beverage or medication of the day or ≥2 hours apart from food, beverage or medication at any other time of the day or ≥30 minutes before bedtime
    • In an upright position, swallow the tablet whole; do not chew, crush or suck
    • Do not lie down for ≥30 minutes following administration to facilitate drug delivery to stomach and to avoid esophageal irritation
  • Calcium and Vitamin D supplementation is recommended if inadequate dietary intake. Separate administration from Risedronic acid by few hours
Zoledronic acid Prevention of postmenopausal osteoporosis: 5 mg IV infusion over 15-30 minutes every other year
Treatment of postmenopausal osteoporosis and osteoporosis in men:
5 mg IV infusion over 15-30 minutes once a year
Prevention and treatment of GIOP: 5 mg IV infusion over 15-30 min once a year		 Adverse Reactions
  • Musculoskeletal effects (increased bone pain from mineralization defect, back pain, myalgia, joint pain); GI effects (diarrhea, nausea/vomiting); CNS effects (headache, dizziness, fatigue); Other effects (dyspnea, depression, eye pain, hypocalcemia, fever)
Special Instructions
  • Avoid in patients with severe renal impairment
  • Patients should be appropriately hydrated prior to and throughout treatment
  • There is a US FDA notice that bisphosphonates, approved to treat osteoporosis, are associated with possible risk of atypical subtrochanteric and diaphyseal femur fractures
  • Consider periodic re-evaluation of the need for continued bisphosphonate therapy especially in patients who have been treated for >5 years
  • Administer in a line separate from other medications
  • Calcium and Vitamin D supplementation is recommended if inadequate dietary intake
Calcitonin
Calcitonin
(Calcitonin salmon,
Salcatonin) 		Treatment of postmenopausal osteoporosis:
50-100 IU SC/IM 24 hourly or
50-100 IU SC/IM every other day
or
50-200 IU intranasally in 1 nostril 24 hourly 		Adverse Reactions
  • Parenteral administration: Transient GI effects after injection (nausea/vomiting, diarrhea, abdominal pain); flushing, dizziness, headache
  • Intranasal administration: Nasal irritation and bleeding, rhinitis, sinusitis, backache and headache (uncommon)
  • Less frequent side effects with nasal route
Special Instructions
  • Alternate the nostril used daily
  • Calcium and Vitamin D supplementation is recommended if inadequate dietary intake
Parathyroid Hormone (PTH) Analogs
Abaloparatide Treatment of postmenopausal osteoporosis and osteoporosis in men:
80 mcg SC 24 hourly
Duration of treatment: ≤24 months		 Adverse Reactions
  • GI effects (nausea, upper abdominal pain); CNS effects (headache, vertigo); Other effects (orthostatic hypotension, palpitations, fatigue, hypercalciuria, hypersensitivity reactions, injection site reactions)
Special Instructions
  • Administer as SC injection in the periumbilical region
  • Advise patients to sit or lie down if symptoms of orthostatic hypotension develop after dose administration
  • Avoid use in patients with increased risk of osteosarcoma or with pre-existing hypercalcemia and those known to have an underlying hypercalcemic disorder
  • Monitor urine Calcium if pre-existing hypercalciuria or active urolithiasis is suspected
  • Calcium and Vitamin D supplementation is recommended if inadequate dietary intake
Teriparatide Treatment of postmenopausal osteoporosis, osteoporosis in men and GIOP:
20 mcg SC 24 hourly
Duration of treatment:
18-24 months		 Adverse Reactions
  • Injection site reactions
  • Hypercalcemia, orthostatic hypotension, dizziness, nausea and headache occur at higher doses
Special Instructions
  • Avoid use in patients with increased risk of osteosarcoma (ie Paget's disease, prior radiation), with history of skeletal metastases, hyperparathyroidism, or pre-existing hypercalcemia
    • Has been associated with an increase in osteosarcoma based on animal studies
  • Calcium and Vitamin D supplementation is recommended if inadequate dietary intake
Sclerostin Inhibitor
Romosozumab Treatment of postmenopausal osteoporosis:
210 mg SC (2 SC injections of 105 mg each) once monthly x 12 months		 Adverse Reactions
  • Musculoskeletal effects (arthralgia, muscle spasms, osteonecrosis of the jaw, atypical subtrochanteric and diaphyseal femoral fractures); Other effects (headache, hypersensitivity, hypocalcemia, injection site reactions)
  • May increase the risk of stroke, MI and CV death
Special Instructions
  • Administer SC injection in the abdomen, thigh, or upper arm; after first injection, immediately give second injection but at a different site
  • Should not be initiated in patients with MI or stroke within the past year
  • Discontinue treatment if MI, stroke or a clinically significant allergic reaction occurs
  • Contraindicated in patients with hypocalcemia or known hypersensitivity to Romosozumab
  • Monitor for signs of atypical femoral fracture or osteonecrosis of the jaw
  • Calcium and Vitamin D supplementation is recommended during treatment
Selective Estrogen Receptor Modulators (SERMs)
Bazedoxifene3 Prevention and  treatment of postmenopausal osteoporosis:
20 mg PO 24 hourly 		Adverse Reactions
  • Hot flushes, leg cramps, peripheral edema, thromboembolic events (DVT, pulmonary embolism)
  • Bazedoxifene: Dry mouth, somnolence, increased triglycerides and liver enzymes
Special Instructions
  • Contraindicated in patients with venous thromboembolic events (DVT, pulmonary embolism, retinal vein thrombosis), unexplained uterine bleeding, signs/symptoms of endometrial cancer
  • Calcium and Vitamin D supplementation is recommended if inadequate dietary intake
Raloxifene Prevention and treatment of postmenopausal osteoporosis:
60 mg PO 24 hourly
Vitamin D Analogs
Alfacalcidol4 Initial dose: 0.5-1 mcg PO 24 hourly
Maintenance dose:
0.25-2 mcg PO 24 hourly 		Adverse Reactions
  • Hypercalcemia which may result in thirst, polyuria, constipation, muscle weakness, fatigue and confusion
Special Instructions
  • Alfacalcidol: Monitor serum Ca every 1-4 weeks initially. If hypercalcemia occurs, stop treatment immediately until serum Ca normalizes (1 week), then restart with half the previous dose
  • Calcitriol: Monitor serum Calcium and creatinine levels at 4 weeks, 3 months and 6 months then every 6 months thereafter. If hypercalcemia occurs, stop treatment immediately until serum Calcium normalizes
  • Avoid Calcium supplementation to avoid risk of hypercalcemia and renal stones
Calcitriol5 Postmenopausal osteoporosis:
0.25 mcg PO 12 hourly
May increase dose monthly based on patient's response
Max dose: 0.5 mcg PO 12 hourly
Colecalciferol
(Cholecalciferol)4		 800-1,000 IU PO 24 hourly or
25,000 IU PO monthly or
25 mcg PO 24 hourly 		Adverse Reactions
  • GI disturbances, hypersensitivity reactions
Special Instructions
  • Use with caution in patients with arteriosclerosis, cardiac conditions, hyperlipidemia, liver disease, renal impairment, sarcoidosis or other granulomatous disease; concomitant use with Calcium- and other Vitamin D-containing preparations, D-analog or thiazide diuretics
  • Avoid in patients with hypercalcemia, metastatic calcification, severe renal impairment
Vitamin K
Menatetrenone 15 mg PO 8 hourly Adverse Reactions
  • GI effects (abdominal pain, epigastric discomfort, dyspepsia, diarrhea); Other effects (rash, erythema, pruritus, headache)
Special Instructions
  • Avoid use in patients on Warfarin therapy
  • Discontinue if rash, redness, pruritus or other symptoms occur
Other Drugs Affecting Bone Structure and Mineralization
Denosumab Treatment of men and postmenopausal women at high risk for fracture and GIOP: 60 mg SC as single dose once every 6 months Adverse Reactions
  • Dermatologic effects (eczema, dermatitis, cellulitis); Musculoskeletal effects (arthralgia, back pain, osteonecrosis of the jaw, atypical femoral fractures); Other effects (hypercholesterolemia, cystitis, cataracts)
Special Instructions
  • Avoid use in patients with hypocalcemia
  • Use with caution in patients with severe renal and hepatic impairment, impaired immune system
  • Calcium and Vitamin D supplementation is recommended
Hydroxyapatite compound
(Ossein-hydroxyapatite compound)4		 1,600-3,200 mg PO 12 hourly Adverse Reactions
  • Occasional mild constipation, insomnia, trembling, mydriasis, euphoria
Special Instructions
  • Avoid in patients with hypercalcemia and hypercalciuria, severe renal failure, urolithiasis; parenteral Calcium in digitalized patients
  • Use with caution in patients with impaired renal function, history of renal stone formation, paraplegia
  • Monitor urine and blood Calcium during parenteral therapy
  • Avoid simultaneous administration with tetracyclines and Na fluoride
Strontium ranelate Treatment of postmenopausal osteoporosis and osteoporosis in men:
2 g PO 24 hourly 		Adverse Reactions
  • CNS effect (headache); GI effects (nausea, diarrhea); Dermatologic effects (dermatitis, eczema, drug rash with eosinophilia systemic symptoms [DRESS])
Special Instructions
  • Dilute in a glass of water, administer orally at bedtime
  • Should be taken 2 hours apart from intake of food, milk and drugs containing Calcium, and 2 hours prior to taking antacids
  • Suspend treatment while on oral tetracycline and quinolone therapy
  • Use with caution in patients with severe renal disease, being treated or who have been treated for blood clots, on prolonged immobilization
1Other bisphosphonates are not yet approved for prevention/treatment of osteoporosis. American Association of Clinical Endocrinologists (AACE) suggests Pamidronic acid IV may be an alternative to patients intolerant of oral bisphosphonate administration.
2Combination with Calcium citrate is available. Please see the latest MIMS for specific formulations and prescribing information.
3Combination with conjugated estrogens is available. Please see the latest MIMS for specific formulations and prescribing information.
4Various combinations with Calcium salts and other vitamins/minerals are available. Please see the latest MIMS for specific formulations and prescribing information.
5Combination with Alendronate is available. Please see the latest MIMS for specific formulations and prescribing information.

Anabolic Agent

Drug Dosage Remarks
Nandrolone decanoate Treatment of postmenopausal osteoporosis and osteoporosis due to androgen deficiency in hypogonadal males:
25-100 mg deep IM once every 3-4 weeks		 Adverse Reactions
  • Virilization in women (amenorrhea); oligospermia and decreased ejaculatory volume, inhibition of spermatogenesis, overstimulation in elderly males, fluid and salt retention
Special Instructions
  • Use with caution in patients with cardiac failure, renal or hepatic dysfunction, hypertension, epilepsy, migraine
  • Avoid use in patients with prostatic or breast carcinoma

Androgens & Related Synthetic Drugs

Drug Dosage Remarks
Testosterone undecanoate1 Osteoporosis due to androgen deficiency:
Initial dose:
120-160 mg PO 24 hourly x 2-3 weeks
Maintenance dose:
40-120 mg PO 24 hourly 		Adverse Reactions
  • Oligospermia and decreased ejaculatory volume, priapism and signs of excessive sexual stimulation, fluid and salt retention
Special Instructions
  • Use with caution in patients with CV disorders, renal and hepatic impairment, epilepsy, migraine, DM
  • Avoid use in patients with prostatic or breast carcinoma
1Various types of testosterone are available to treat hypogonadotropic states. Please see the latest MIMS for specific formulations and prescribing information.

Calcium* & Vitamin D

Drug Elemental Ca1 Available Strength Dosage/Remarks
mg/g mEq/g
Calcium acetate 253 12.63 1,000 mg/tab (elemental Ca 253 mg) 500-1,000 mg of elemental Ca PO 24 hourly

Adverse Reactions
  • GI effects (GI irritation, constipation)
Calcium carbonate 400 19.96 350 mg/cap (elemental Ca 140 mg)
500 mg/tab (elemental Ca 200 mg)
835 mg/cap (elemental Ca 334 mg)
1,000 mg/tab (elemental Ca 400 mg)
1,250 mg/tab (elemental Ca 500 mg)
1,500 mg/tab (elemental Ca 600 mg)
Calcium citrate 211 10.53 950 mg/tab (elemental Ca 200 mg)
1,500 mg/tab (elemental Ca 315 mg)
Calcium gluconate 93 4.64 1,000 mg/tab (elemental Ca 90 mg)
Calcium lactate 130 6.5 325 mg/tab (elemental Ca 42 mg)
650 mg/tab (elemental Ca 84 mg)
Vitamin D - - Various strengths and combinations with other vitamins/minerals are available 400-800 IU PO 24 hourly

Adverse Reactions
  • Hypercalcemia from overdose which can lead to anorexia, nausea/vomiting, diarrhea, thirst, vertigo
*Other Calcium salts, various strengths and combinations with Vitamin D and other vitamins/minerals are available. Please see the latest MIMS for specific formulations and prescribing information.
1Reference: Weill Cornell Medical College. Calcium Equivalents. Jun 2011. http://www-users.med.cornell.edu.

Other Estrogen

Drug Dosage Remarks
Tibolone Prevention of postmenopausal osteoporosis: 2.5 mg PO 24 hourly Adverse Reactions
  • Irregular vaginal bleeding/spotting usually during first few months of therapy, changes in body weight, ankle edema, skin reactions, facial hair growth, headache, GI disturbances, altered liver function
Special Instructions
  • To be administered for at least 3 months for optimal effect
    • To be swallowed whole without chewing at the same time each day
  • Should not be used if woman has hormone-dependent tumors, CV or cerebrovascular disorders (including thrombophlebitis), undiagnosed vaginal bleeding, pregnant or lactating, or has severe liver disorders
  • Use with caution in patients with disorders that may be aggravated by fluid retention, hypercholesterolemia, impaired glucose tolerance
  • Use within 12 months of menopause is not recommended because of irregular bleeding that may occur
  • Bleeding that starts after 3 months of therapy should be investigated
  • Discontinue treatment if thromboembolism, abnormal LFT or jaundice occurs

Disclaimer

All dosage recommendations are for non-pregnant and non-breastfeeding women, and non-elderly adults with normal renal and hepatic function unless otherwise stated.  
Not all products are available or approved for above use in all countries.  
Products listed in the Drug Summary are based on indications stated in the locally approved product monographs.   
Please refer to local product monographs in Related MIMS Drugs for country-specific prescribing information. 

Related MIMS Drugs