Agent	Effect on fracture risk (level of evidence)
	Vertebral	Nonvertebral	Hip	Adverse effects	FDA approval
Bisphosphonates
Alendronate (Fosamax)	Decreased (strong)	Decreased (strong)	Decreased (strong)	Mild upper GI events, esophageal ulcerations, perforations, bleeding events	Prevention or treatment
Etidronate (Didronel)	Decreased (strong)	No effect (fair)	No effect (strong)	Mild upper GI events, esophageal ulcerations, perforations, bleeding events	Not approved for prevention or treatment
Ibandronate (Boniva)	Decreased (strong)	No effect (strong)	Not studied	Esophageal ulcerations, perforations, bleeding events	Prevention or treatment
Pamidronate (Aredia)	No effect (weak)	No effect (weak)	No effect (weak)	Mild upper GI events, esophageal ulcerations, perforations, bleeding events	Not approved for prevention or treatment
Risedronate (Actonel)	Decreased (strong)	Decreased (strong)	Decreased (strong)	Esophageal ulcerations, perforations, bleeding events	Prevention or treatment
Zoledronic acid (Reclast)	Decreased (strong)	Decreased (strong)	Decreased (strong)	Muscular and joint pain	Prevention
Calcitonin (Miacalcin)	Decreased (fair)	No effect (strong)	Not studied	No clinically significant adverse effects	Treatment
Calcium and vitamin D	Modest effect* (strong)	Modest effect* (strong)	Modest effect* (strong)	No clinically significant adverse effects	Over the counter
Estrogen	Decreased (strong)	Decreased (strong)	Decreased (strong)	Thromboembolic events; cerebrovascular accident, stroke, and breast cancer (when combined with progestin); gynecologic problems (endometrial bleeding); breast abnormalities (pain, tenderness, fibrocytosis)	Prevention
Selective estrogen receptor modulators
Raloxifene (Evista)	Decreased (strong)	No effect (strong)	No effect (strong)	Pulmonary embolism, thromboembolic events	Prevention or treatment
Tamoxifen (formerly Nolvadex)	No effect (strong)	Not studied	No effect (strong)	Pulmonary embolism	Not approved for prevention or treatment
Teriparatide (Forteo)	Decreased (strong)	Decreased (fair)	No effect (weak)	No clinically significant adverse effects	Treatment
Testosterone	Not studied	Not studied	Not studied	No clinically significant adverse effects	Not approved for prevention or treatment