Alternatives to Fosamax: the ultimate guide

Fosamax (alendronate) is a medical drug for treatment of osteoporosis. But do you know about its alternatives? This article features an evidence based look at both medical (Risedronate, Ibandronate, Zoledronic acid, Miacalcin, Forteo, Prolia and Raloxifene) and natural (calcium, vitamin D, boron and regular exercise) alternatives to Fosamax.

This post does not replace proper medical treatment. You should always go and see your doctor and follow his/her advice to get a proper treatment for osteoporosis. This post just gives you information about all available alternatives to Fosamax.

About Fosamax

Fosamax (alendronate) belongs to a group of drugs called bisphosphonates. Fosamax helps prevent and treat osteoporosis (1). Osteoporosis is a disease that effects the bones. It is commonly called “brittle bone disease” and the literal meaning of osteoporosis is “porous bones”. It can occur either due to excess bone loss or inadequate bone formation. The bones become thin and break easily. The chances of osteoporosis increase with age and steroid use. It is more common in women compared to men.

Main symptoms of osteoporosis:

• Back pain (due to fractured or collapsed vertebra)
• Loss of height with time
• Hunched posture
• Bone fractures

Fosamax works by altering the cycle of bone formation and deposition. Fosamax helps slow down bone loss while increasing bone formation; thus preventing bone fractures. Different drugs treat different forms of osteoporosis. Fosamax mainly treats osteoporosis due to menopause and steroid use. It is also used for the treatment of Paget’s disease- a bone disease which results in fragile bones. It also helps increase bone mass in men suffering from osteoporosis.

Side effects and precautions of Fosamax

Fosamax is a great drug for the treatment of osteoporosis. But like every drug it has its pros and cons. Fosamax can cause allergic reaction in certain people. If your notice any signs of allergic reaction contact your doctor at once.

Here are the common symptom of an allergic reaction to Fosamax (2):

• Hives
• Rash
• Facial swelling
• Difficulty breathing

Given below are some common side effects of Fosamax (3):

• Mild heartburn
• Bloating
• Mild nausea or vomiting
• Diarrhea
• Mild joint pain or swelling
• Dizziness
• Headache.

Here are some drugs that may interact with Fosamax (4):

• Deferasirox
• Aspirin
• Calcium 600 D (calcium / vitamin d)
• Folic acid
• Gabapentin
• Lasix (furosemide)
• Levothyroxine

You should not use Fosamax if you have the following conditions (5):

• Hypoglycemia
• Upper gastric mucosal irritation
• Renal dysfunction

Medical alternatives to Fosamax

Osteoporosis is a serious problem especially in women over 50 years. Fosamax is used to prevent and treat osteoporosis. But some people might be allergic to it or it might not suit them. Drugs like aspirin and furosemide can cause a drug interaction with fosamax. So if you are taking them, avoid fosamax and use an alternative. If you suffer from hypoglycemia (low blood sugar) or renal (kidney) disease then try to avoid Fosamax.

But do not worry - there are many alternatives to Fosamax available on the market. In this section we are going to talk about some of the pharmaceutical alternatives to Fosamax. Always remember to consult your doctor before starting or changing any drug.

Risedronate (Actonel)

Risedronate is a drug that is used for the treatment and prevention of osteoporosis (6). It is mainly used in perimenopausal women. Risedronate belongs to the bisphosphonate group of drugs.  Risedronate works by slowing down bone resorption. It inhibits the cells (osteoclasts) that cause bone breakdown.

Fosamax vs Risedronate

Fosamax and Risedronate belong to the same class of drugs. Researches are being conducted to determine which one is more effective. Few studies show that fosamax is more effective than risedronate. Fosamax, when compared to risedronate, has significantly greater BMD (bone mineral density) gain. It means Fosamax causes a better increase in bone density compared to risedronate. Both these drugs have the same upper gastrointestinal (UGI) tolerability. The main concerns with fosamax use are nausea and arthritis. While joint and back pain are main side effects of risedronate.           

Indications

Risedronate is used for the treatment of osteoporosis and other bone disease. There are many different type of osteoporosis and different drugs are used for their treatment. Following are the indications of risedronate:

Post menopause osteoporosis

• Glucocorticoid induced osteoporosis (due to steroid intake)
• Paget’s disease (osteitis deformans) 

How to use?

When taking delayed release tablets do not chew or crush them. Take delayed release tablets with at least 4 oz. of plain water. Do not take it with coffee, juice or tea. After taking risedronate tablets do not take any other medication or lie down for at least 30 minutes. Do not take risedronate with food because food hinders its absorption in the gut. Take medication in the morning about 30 minutes before breakfast.  

Side effects and drug interactions

While taking any drug there are some dos and don’ts that you need to follow. Risedronate is a bisphosphonate that can cause interaction with other drugs. If you notice any signs of allergic reaction to risedronate contact your doctor at once. The side effects of risedronate can range from mild to moderate.

Following are a few common side effects of Risedronate (7):

• Headache
• Joint pain
• Abdominal discomfort
• Diarrhea
• Rash
• Nausea

Risedronate is contraindicated in people with (8):

• Hypoglycemia
• Renal disease
• Upper gastric mucosal irritation

Following are a few drugs that are known to interact with Risedronate (9):

• Deferasirox
• Aspirin
• Calcium 600 D (calcium / vitamin d)
• Calcium Concentrate (calcium carbonate)
• Calcium Oyster (calcium carbonate)
• Fish Oil (omega-3 polyunsaturated fatty acids)
• Lipitor (atorvastatin)

Dosage

Risedronate tablets are available in 5, 30, 35 and 150 mg strengths (10). Risedronate is also available in form of delayed release capsules.

For postmenopausal women 5 mg daily or 35 mg weekly is the suitable dose.

For men with osteoporosis and for steroid induced osteoporosis 35 mg weekly is the recommended dose.

For people with Paget’s disease 30 mg daily for 2 months is the suitable dose.

Ibandronate (Boniva)

Ibandronate is a nitrogen containing bisphosphonate (11). It is indicated in women who are post menopause. In postmenopausal women there is an increased rate of bone loss. Studies have shown that ibandronate helps reduce bone resorption and increase bone density.

Fosamax vs Ibandronate

Both these drugs belong to the same class of drugs – bisphosphonates. Fosamax is used for prevention and management of different types of osteoporosis, while ibandronate is mostly used for the treatment of osteoporosis in menopausal women. The main side effects of fosamax are nausea and arthritis. While the main concerns with ibandronate use are joint and back pains.     

Indications

The main indication of ibandronate is osteoporosis in menopausal women.   

How to use?

Ibandronate has to be taken once a month orally. Make sure to set reminders so you do not miss a dose. The intravenous injection of ibandronate is a technical thing. So contact your physician in regard to IV injection of ibandronate.

Side effects and drug interactions

Following are the common side effects of ibandronate (12):

• Joint pain
• Back pain
• Nausea
• Arthritis
• Flu symptoms
• Stomach upset

Here are some drugs known to interact with ibandronate:

• Botulism immune globulin
• Cytomegalovirus immune globulin
• Deferasirox
• Efavirenz
• Immune globulin intravenous and subcutaneous
• Sirolimus
• Tenofovir

People with the following conditions should use ibandronate with caution:

• Kidney dysfunction
• Pregnancy or lactation
• Chemotherapy or radiotherapy
• Hypoglycemia

Dosage

Ibandronate is present in the form of tablets and intravenous injections.

The oral dose of ibandronate is 150 mg once a month (13). Make sure to take the tablet on the same day of each month.

3 mg of intravenous injection over 20 to 30 second is indicated for treatment of osteoporosis. The injection is repeated every 3 months. 

Zoledronic acid (Reclast)

Zoledronic acid is a bisphosphonate. It is used in the treatment of certain types of osteoporosis. Zoledronic acid is also used in combination with other drugs for the management of certain cancers (14). Zoledronic acid is mainly used to control the high blood calcium levels caused by cancer. Zoledronic acid reduces the breakdown of bone. Thus decreasing the amount of calcium released into blood due to bone breakdown. 

Fosamax vs Zoledronic acid

Both these drugs belong to the bisphosphonate group of drugs. The main indication of fosamax is prevention and treatment of osteoporosis, while zoledronic acid is mainly used as an adjuvant in cancer therapy. The main side effects of fosamax are nausea and arthritis. While the main concerns with zoledronic acid use are tiredness and flu like symptoms.        

Indications

Following are the indications of zoledronic acid:

• Osteoporosis in men
• Osteoporosis in postmenopausal women
• Certain types of cancers (multiple myeloma or breast cancer)
• Paget’s disease

How to use?

Zoledronic acid has to be given as an infusion. That has to be done in a hospital setting.  

Side effects and drug interactions

Like all drugs in the market zoledronic acid also has side effects (15). If you are taking zoledronic acid and notice any signs of allergic reaction contact your doctor at once.

The common side effects of zoledronic acid are as follows:

• Dizziness
• Headache
• Flu like symptoms
• Muscle pain (at injection site)
• Muscle cramps

Here are the drugs that can interact with zoledronic acid:

• Corticosteroids (prednisone)
• Aminoglycoside antibiotics (gentamicin)
• Botulism immune globulin
• Cidofovir
• Deferasirox
• Emtricitabine
• Immune globulin intravenous and subcutaneous
• Sirolimus
• Tacrolimus
• Tenofovir

Dosage

Zoledronic acid is available in the form of intravenous infusion (16).  

For the management of hypercalcemia of malignancy: 4 mg zoledronic acid infusion over 15 minutes is given. If serum calcium levels do not return to normal then another dose is give after 7 days.

For treatment of osteoporosis: 5 mg infusion of Zoledronic acid is given over at least 15 minutes. The use of calcium and vitamin D is also recommended with zoledronic acid use.  

Miacalcin (calcitonin)

Miacalcin is a man-made form of hormone. This hormone is naturally found in the thyroid gland. Miacalcin is present in the form of nasal spray and injection. Miacalcin is used for the treatment of osteoporosis in women who have been menopausal for 5 years (17). 

Fosamax vs Miacalcin

Fosamax belongs to bisphosphonate class of drugs, while miacalcin is a man-made hormone. Both these drugs are used for the management osteoporosis. But fosamax can also help prevent osteoporosis. The main concerns with fosamax use are arthritis and nausea. While the common side effects of miacalcin are bone pains and stomach upset.        

Indications

Following are a few indications for the use of miacalcin (18):

• Osteoporosis in menopausal women
• Hypercalcemia associated with malignancy
• Paget’s disease

How to use?

The injections should be administered by a professional to avoid any complications. So contact your physician. Miacalcin is also available in from of nasal spray. Given below are the steps on how to use miacalcin nasal spray:

• Shake the bottle
• Blow your nose gently
• Keep your head upright and insert the tip of the bottle into your nostril
• Close your other nostril with your finger
• Now press the spray. You do not need to inhale deeply or sniff
• Repeat the process with the other nostril
• Do not blow your nose for a few minutes after using nasal spray.

Side effects and drug interactions

If you are taking miacalcin and notice and signs of allergic reaction contact your doctor immediately (19). The common signs of allergic reaction are:

• Breathing problems
• Rash
• Facial swellings
• Hives

Here are the common side effects of miacalcin:

• Nausea
• Vomiting
• Abdominal pain
• Diarrhea
• Altered taste sensation 

The following drugs may interact with miacalcin:

• Cimetidine
• Foscarnet
• Lithium
• Morphine
• Naltrexone

Dosage

Miacalcin is present in the form of nasal sprays and injections. Miacalcin nasal spray should be reserved for people for whom alternative options are unsuitable - like people who are unwilling to take oral medication or get injections. Nasal spray is the less effective form of osteoporosis treatment compared to tablets and injections. Miacalcin is given as 100 international units every other day. Or it is given as 50 international units once a day either subcutaneously or intramuscularly (20). 

Forteo (Teriparatide)

Forteo is a man-made hormone. It resembles parathyroid hormone that occurs naturally in the body. The active agent in forteo is teriparatide (21). Forteo is used for the treatment of osteoporosis in men and women. Forteo helps increase bone density and strength. Thus decreasing the risk of bone fractures.    

Fosamax vs Forteo

Forteo is a man-made hormone, while fosamax belongs to bisphosphonate group of drugs. Both these drugs are used for the management of osteoporosis. But fosamax also helps prevent osteoporosis in menopausal women. Fosamax is more commonly recommended by doctors. The common side effects of fosamax are nausea and arthritis. While the common concerns with forteo use are weight gain and dizziness.     

Indications

These are Forteo drug indications:

• Osteoporosis in menopausal women
• Osteoporosis in men
• Steroid induced osteoporosis

How to use?

Forteo should be administered subcutaneously in the abdominal wall or thigh. When the injection is given the patient should be lying down or siting so that they don’t fall down if the experience orthostatic hypertension- the decrease in blood pressure after getting up.   

Side effects and drug interactions

Forteo has pros and cons like every drug in the market. Allergic reaction to drugs can be life threating. So if you notice any signs of allergic reaction contact your doctor at once.

These are the common side effects of Forteo (22):

• Weight gain
• Nausea
• Dizziness
• Abdominal pain
• Metallic taste

The following drugs may interact with Forteo:

• Betamethasone
• Calcipotriene topical
• Calcitriol topical
• Digitoxin
• Digoxin
• Furosemide

Dosage

Forteo is available in the form of injectable solution (23). 20 mg of Forteo is given subcutaneously once daily. This dose is same form women and men.  

Prolia (Denosumab)

Prolia is a monoclonal antibody. This means that it is designed to target and destroy certain cells. Thus preserving the healthy cells. Prolia is used for the treatment of osteoporosis. It helps increase bone mass in men and women. It is also given as an adjuvant in cancer therapy in certain patients (24).

Fosamax vs Prolia

Prolia is a monoclonal antibody, while fosamax is a bisphosphonate. Both these drugs are used for the management of osteoporosis. But fosamax can also help prevent osteoporosis. The common side effects of prolia are tiredness and bone pains. While the common side effects of fosamax are nausea and arthritis.         

Indications

Following are the indications of prolia use:

• Osteoporosis
• Bone metastases
• Multiple myeloma
• Giant cell tumors of bone
• Certain cancers  

How to use?

Prolia is given subcutaneously in the abdominal wall or thigh. The dose of prolia is repeated every 6 months. It should be administered by a healthcare professional to avoid any complications. The use of prolia can cause dental problems. So make sure to practice good oral hygiene. 

Side effects and drug interactions

Get emergency medical help if you notice any sign of allergic reaction after taking prolia. Every drug along with its benefits also has some side effects (25).

These are the common side effects of Prolia:

• Tiredness
• Muscle pain or soreness (at site of injection)
• Fever
• Bladder infection
• Bone pains

The following drugs are known to interact with Prolia:

• Cortisone
• Cyclophosphamide
• Cyclosporine
• Dexamethasone / lidocaine
• Fludrocortisone
• Fluorouracil
• Gemcitabine
• Hydrocortisone
• Ibandronate
• Levamisole
• Methotrexate
• Methylprednisolone
• Mycophenolic acid
• Prednisone

Dosage

60 mg of subcutaneous prolia every 6 months is the recommended dose for osteoporosis treatment (26).

Raloxifene (Evista)

Raloxifene is a selective estrogen receptor modulator (SERM). It is used to prevent and treat osteoporosis. Raloxifene prevents bone loss and makes the bone strong (27). Thus making bone fractures in postmenopausal women less likely. It also helps reduce the risk of invasive breast and uterine cancer. It works by blocking the estrogen receptors in the uterus and breasts.  

Fosamax vs Raloxifene

Fosamax is a bisphosphonate, while raloxifene is a selective estrogen receptor modulator. Both these drugs are used to prevent and treat osteoporosis. The common side effects of fosamax are nausea and arthritis. While the main concerns with raloxifene use are hot flashes and blood clots.     

Indications

Following are the indications for the use of Raloxifene:

• Osteoporosis
• To reduce the risk of invasive cancer

How to use?

Raloxifene is available in form of tablets. You can take the drug with or without food. Make sure to take the drug at the same time every day. If you miss a dose do not take a double does.

Side effects and drug interactions

Contact your doctor at once if you notice signs of allergic reaction after taking raloxifene (28).  

These are the common side effects of Raloxifene:

• Blood clots
• Leg cramps
• Hot flashes
• Nausea
• Weight gain

The following drugs can interact with raloxifene (29):

• Bexarotene
• Lenalidomide
• Pomalidomide
• Thalidomide
• Tranexamic acid

People with the following conditions should avoid using raloxifene:

• Liver disease
• Thromboembolism

Dosage

60 mg of Raloxifene daily is recommended for treatment of osteoporosis (30). 

Natural alternatives to Fosamax

Osteoporosis is a disease that affects the bones. In the last few decades there has been an increase in the incidence of osteoporosis. Bisphosphonates are mostly used for the prevention and management of osteoporosis. But along with their benefits they also have side effects. One of the main negative effects of bisphosphonate use is compromised immunity.

So people are now looking for natural alternatives so that they can avoid the side effects of pharmaceutical drugs. Many researchers are working on finding a natural treatment of osteoporosis. But so far the natural alternatives are few and untested. In this section we are going to talk about few of the alternatives that are available and are effective.

Calcium

Calcium is an important nutrient for the proper health of body. Calcium plays a key role in prevention of osteoporosis (31). Calcium helps the formation of bones. And this in turn increase the bone mass and prevents fractures due to osteoporosis. Not is calcium abundantly present in dairy and fruits but now it is also present in packaged foods. There are also many calcium supplements available in the market.

The bones throughout our life undergo breakdown and formation. The pace of loss and formation of bone differs with age. After age of 50 especially in menopausal females excess bones loss can occur compared to bone formation.  This is due to drop in estrogen levels and can lead to osteoporosis (32).

As a person grows their calcium requirements change. So they should adjust there intake accordingly. The daily requirement of calcium depends on age and gender (33). 

Calcium Recommended Daily Allowances
Age range (years)	Calcium recommended daily dose (mg/day)
9 - 18	1 300
19 - 50 51 - 70 (men)	1 000
51 - 70 (women) Over 70 (men and women)	1 200

There are many different forms of calcium supplements available in the market. The most common are:

• Calcium citrate
• Calcium gluconate
• Calcium lactate
• Calcium carbonate

Calcium carbonate is not easily absorbed in the body. But it contains the highest amount of element calcium. 1200 mg of calcium daily is recommended for prevention and treatment of osteoporosis in post-menopausal women. 

When taking calcium supplements remember the following things:

• More isn’t always better. Excess of calcium can also cause certain side effects (34).
• If you are taking any other medication consult with your doctor. Because calcium might cause interaction with it. 

The following drug are known to interact with calcium (35, 36):

• Abacavir
• Calcitriol
• Dolutegravir
• Doxercalciferol
• Paricalcitol
• Sodium polystyrene sulfonate
• Diuretics
• Digoxin
• Corticosteroids
• Alendronate
• Antacids containing aluminum
• Blood pressure medication
• Anti-seizure medication
• Gentamicin and other antibiotics
• Levothyroxine

Vitamin D

Vitamin D is essential for the formation and maintenance of bone (37). Because vitamin D helps the body absorb calcium from the gut. Vitamin D is formed in the body when skin is exposed to ultraviolet rays (sun). The amount of vitamin D formed due sun exposure depends on:

• Time of the day.
• Where you live in the world.
• Skin color.
• Duration of exposure too sun.

The type of vitamin D formed in the body is vitamin D3 (cholecalciferol). Whereas the dietary form of vitamin D can be vitamin D3 or vitamin D2 (ergocalciferol). Vitamin D2 has a plant origin.

The following foods are high in vitamin D content:

• Cod liver oil
• Salmon
• Sardine
• Eggs
• Liver

Vitamin D deficiency can be due to insufficient sun exposure or inadequate dietary intake.

Deficiency of vitamin D can cause growth retardation and bone deformities in children. While in adults the deficiency of vitamin D can cause osteoporosis. Vitamin D helps the body to absorb calcium more effectively. This helps with the formation and renewal of bones. And it also improves muscle functions. Thus in turns improves balance and decrease the risk of fracture due to falls.  

Supplements of vitamin D are recommended to following people:

• Elderly people
• People who live in colder areas with little sun exposure
• People who do not go outdoor much
• People whose body can not properly synthesize vitamin D.

Institute of Medicine's expert committee set these “dietary reference intake” of vitamin D in 2010 (38).

Age	Daily requirement	Maximum upper safety limit
0 to 6 months	400 IU/day	1,000 IU/day
6 to 12 months	400 IU/day	1,500 IU/day
1-3 years	600 IU/day	2,500 IU/day
4-8 years	600 IU/day	3,000 IU/day
9-70 years	600 IU/day	4,000 IU/day
71+ years	800 IU/day	4,000 IU/day

Many multivitamins also contain vitamin D. The use of supplementary vitamin D is recommended with calcium. Doctors also recommend the use of vitamin D with certain drugs used for treatment of osteoporosis.

These drugs may interact with vitamin D:

• Steroids (prednisone)
• The weight loss drug orlistat (Xenical and Alli)
• Cholesterol-lowering drug (cholestyramine)
• Seizure drugs (Phenobarbital and Dilantin)

Boron

Boron is a mineral that is naturally found in food and environment. Boron supplements are also available in the market. Boron is used for the management and prevention of osteoporosis (39). Boron helps the formation of strong bones. Thus reducing the risk of osteoporosis. Following are the ways in which boron helps fight osteoporosis:

• Boron affects the way the body handles other minerals.
• It helps increase the estrogen levels in menopausal women.
• It also helps increase estrogen levels in health men.

The recommended daily intake of boron has not yet been established. A diet is considered high in boron when it has 3.25 mg of boron per 2000 kcal per day. And it’s considered low in boron when it provides 0.25 mg of boron per 2000 kcal per day.

These are the common side effects of excessive boron intake (40):

• Discoloration of feces
• Dermatitis
• Diarrhea
• Epigastric pain
• Nausea
• Vomiting

Boron may slightly increase estrogen levels in the body (41). Therefore its interactions are as follows:

• Estrogen
• Estropipate
• Mestranol

Regular exercise

Regular exercise brings a lot of benefits to your body and an increase in your bone density is one of them (42, 43). Research shows that the prevalence of osteoporosis is lower in elderly individuals who tend to exercise during their youth. This doesn’t mean you shouldn’t exercise as you grow old. Exercise also shows that exercise improves bone mineral density in elderly and is therefore an excellent way to improve bone strength naturally.

The Bottom Line

Fosamax is a great drug for the prevention and treatment of osteoporosis. But it might suitable for certain people. Due to allergic reaction or drug interaction with another medication they might be taking. But not to worry because there are many alternatives to fosamax available in the market. All drugs have their pros and cons. And sometimes the benefits are just not worth the side effects. Natural alternatives have few to no side effects. But there are not many natural alternatives for the treatment of osteoporosis. May studies are being conducted to find better natural alternatives for management of osteoporosis.

Fosamax and risedronate are bisphosphonates that help prevent and treat osteoporosis.

Zoledronic acid and ibandronate are a bisphosphonate that are used for the treatment of osteoporosis in post menopause women. 

Miacalcin and forteo are man-made hormones that are used for the treatment of osteoporosis in both men and women.

Prolia is a monoclonal antibody that helps treat osteoporosis. It also helps fight bone metastases.

Raloxifene is a selective estrogen receptor modulator that helps treat osteoporosis. It also helps reduce the risk of invasive cancers like breast and uterine cancer. 

Calcium helps the formation of bone. This making bones stronger and preventing fractures due to osteoporosis. 

Other natural alternatives to Fosamax include vitamin D, boron and regular exercise.