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risk of atypical fractures (uncommon ) with all treatment .... check risk every 5 years and think ... ? drug holiday ?? 

''bisphosphonates''
alendronate, risedronate, etidronate - all for post men and steroid induced osteoporosis
all reduce vertebral and non-vertebral ~ but etidronate less effective with hips
ibadronate - once monthly oral
gi se can be a problem use 
avoid with ppi as not absorbed 
zolendronate ... yearly infusion beware jaw osteonecrosis 
off license at 4 mg ....

''calcium and vit D ''
cvs risk not a problem with vit d and ca ??
? take diet history 3 portions of dairy per day 
little evidence of effect in general population ? useful in elderly housebound ....

''raloxifene'' (SERM)
shown to prevent bone loss and reduce vertebral fractures but not non-vertebral #
in bone density - spine and femur
?worsen menopausal Sx 
Inc risk VTE
dec risk breast ca

''strontium''
dual action (on blasts and clasts)
dvt and cvs risks so don't use unless from secondary care
skin reactions - Stephen Johnson


''denosumab'' ... twice a year sub cut ... se cellulitis
inhibits RANK ligand which inhibits osteoclasts
effective and well tolerated

''Teriparatide''
recombinant parathormone
v good at inc bone density - role in osteoporosis not yet defined

''HRT''
dec risk vertebral and non-vertebral #
inc CVS and breast ca  - only use for vasomotor Sx

''Hip protectors''
significantly reduce hip fractures in nursing home patients
compliance is a problem

''Falls risk assessment''
no evidence to suggest reduced fracture rates but do reduce rate of falls - so consider in high risk