bisphosphonates like actinel or fosamax work well if you are older. But I worry about brittle bones with these treatments as even though bone density increases, the bones become brittle. Bone formation stimulators are probably best. There is one that is an injection that affects PTH. I would go with that.

I have started Injection Teriperatide 20 mcg S/C OD in a few patients with Calcium suppl....Not completed the course yet, hope to get a good result.

Maybe we should look at Osteoporosis treatment in a slightly different way. Bone strength is what we are really interested in and bone mineral density tells only half the story. Again, lower the bone strength, higher the chances of fragility fractures with low impact accidents. It is really these accidents that we are aiming to prevent. For eg; hip fractures with osteoporosis are associated with a 20% mortality at 1 year which is worse than some cancers.

Fracture prevention has 3 components

a. Strengthening the bone: Almost all group of medicines (bisphosphonates or recombinant parathormone or estrogen analogues or calcium with Vitamin D or any of the othjer agents) only increase the Bone Mineral density by 6-12% over a few years. The choice is dependent on a multitude of factors including patient profile, tolerabilty and likely side effects in a given patient.

b. Fall prevention: This might be the most useful area to intervene. Small changes in house like ensuring no loose toys on floor to trip upon at night, keeping a bedside light on while going to toilet at night, improving vision with timely cataract surgery, timely treatment of neurological disorders prone to falls (like parkinsonism etc) will go a long way in effective therapy. This area is often ignored both by patients and Physicians

c. Impact reduction: In a given patient prone to recurrent falls, various protectors (like hip padding) are available to reduce the probability of fracture.

Unfortunately, today all treatments are around maintaining calcium balance but apart from mineral phase of the bone, matrix phase is also important. Just providing calcium will not serve any purpose because after all calcium has to be suspended into collagen matrix phase to strengthen the bones. In osteoporosis there is also deficiency of collagen matrix. As we know collagen is a protein so along with calcium a source of protein should also be given.

I think prevention is better option. Our diet should be rich in natural form of calcium. If they can afford, everyone should use 1 litre of milk or yogurt especially women from their early years of life.

To treat osteoporosis (OP) a different options are now available.

First point is to clear if the patient has a primary or a secondary OP. In this case the best way could be to correct the primary decease that causes OP.

Many patients with primary OP have also Hypovitaminosis D, that can lead to a secondary Hyperparathiroydism. it is mandatory to correct the vitamin D deficit, before or with the start of the pharmacological treatment of the OP. High doses (up to 1 million of Units in 1-2 months in the elderly patients) of colecalciferol are needed initially and than daily doses of 1.500-2.000 Units.

The supplementation with calcium is needed only if the diet has a calcium content lesser than 600 mg daily.

The antifracturative drugs now available have 3 different ways of action e for this it is possible to classify them in: antiresorptive, anabolic, dual action drugs. All the drugs for OP are effective in reducing the incidence of fragility fractures (from 36% after 1 year to more than 70% in high risk patients)

In the antiresorptives we can find:

Bisphosphonates (alendronate, risendronate, ibandronate, zolendronate are the most used in the world) are the most known drugs for OP and are administered orally (the first three, ore intravenously (the second two) in refracted doses, from 1 week the alendronate, to 1 year the zolendronate.  They inhibit the osteoclastic activity causing their apoptosis by a block of the synthesis of a molecule of the lilidic cell membrane. Because their accumulation in the bone, after a long period treatment it is possible to have two serious collateral effect (Osteonecrosis of the jaws and atypical fracture of the femur) that can be prevented following the patient with attention. Bisphosphonates are also the cheapest (mainly alendonate) drugs for OP. 

Denosumab, a biologic drug (IgG to RANKL), stops the action of osetoclasts inhibiting the osteoclastogenetic way in the same way acts the osteoprotegerin, a natural mediator). It is very potent and its acts for 6 month after the injection. It has the same collateral effects of Bisphosphonates.

In the anabolic we find teriparatide (1-34 PTH) and 1-84 PTH, it depends by the country. PTH at low daily doses (now a weekly dosing is under study) has a prevalent action on the osteoblasts, promoting their differentiation and stimulating their action; the osteoclastic activity is also stimulated, but only temporarily. The effects of this drugs is very impressive for the clinical improving of patient status (reduction of pain, increase of strength). Because of its elevated cost, it is used mainly in severe osteoporosis and because the data of the experimantal data are limited at 2 years, it is usually used only for 2 years (than an anti-resorptive drug is used).

The only known dual action drug is Strontium ranelate, a bivalent ion that binds to calcium sensing receptors, causing a modification in the balance between bone resorption and bone apposition. The most relevant collateral effect is an increase of thrombotic risk, both venous and arterious, so it is now considered a second choice drug.

There is not a better strategy for everyone, but the most fixable strategy for a single patient in his real setting.

But the most important problem in the care of OP is, however, the lack of intervention in the patients with fragility fractures, that, after the treatment of the fracture are not direct to the OP treatment.