HOW TO MANAGE OSTEOPOROSIS when patients don't get enough benefit from a bisphosphonate?! ― Reassess your treatment plan for patients who continue to have significant bone loss, or a fracture, despite being on a bisphosphonate. Continue the basics. Recommend weight-bearing exercise, adequate vitamin D and calcium, etc.
Check adherence. About 50% of patients stop therapy after 1 year. Help patients understand HOW to take the bisphosphonate, and WHY they're taking it. Explain that once a vertebral fracture occurs, the risk of another one increases by about 5-fold. Consider less frequent dosing: alendronate every week, Actonel or ibandronate every month, IV Boniva every 3 months, or IV Reclast yearly. Switch to another osteoporosis medication IF needed. For example, use Forteo (teriparatide) or Prolia (denosumab) for patients at very high fracture risk.
Forteo is the only osteoporosis medication with anabolic effects that stimulate bone growth. The others slow bone resorption. That's why many specialists use Forteo if patients have a fracture while on a bisphosphonate. This isn't "evidence based". But Forteo MIGHT lead to greater improvements in bone strength than antiresorptives. Stop Forteo after a max of 2 years. Then restart a bisphosphonate or another antiresorptive medication to help maintain bone density.
Consider Evista (raloxifene) for women who also want a lower breast cancer risk, or estrogen for women with menopausal symptoms. Don't count on nasal calcitonin. It's not very effective and is associated with a higher risk of cancer.
Be cautious about combining osteoporosis medications. There's no proof that combos lower fracture risk and some combos might be detrimental. For example, combining two antiresorptive medications might inhibit bone turnover too much and INCREASE fracture risk. And combining a bisphosphonate with Forteo might reduce Forteo's bone-building effects.
REFERENCES
Miller, P.D. (2016). Management of severe osteoporosis. Expert Opinion on Pharmacotherapy, [online] 17(4), pp.473–488. Available at: https://pubmed.ncbi.nlm.nih.gov/26605922
Watts, N., Bilezikian, J., Camacho, P., Greenspan, S., Harris, S., Hodgson, S., Kleerekoper, M., Luckey, M., McClung, M., Pollack, R. and Petak, S. (2010). American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Postmenopausal Osteoporosis: Executive Summary of Recommendations. Endocrine Practice, 16(6), pp.1016–1019. Available at: https://pubmed.ncbi.nlm.nih.gov/21216723
Iversen, M.D., Vora, R.R., Servi, A. and Solomon, D.H. (2011). Factors Affecting Adherence to Osteoporosis Medications: A Focus Group Approach Examining Viewpoints of Patients and Providers. Journal of geriatric physical therapy (2001), [online] 34(2), pp.72–81. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181084