This updated Medicines Q&A evaluates the published evidence examining the gastric safety of bisphosphonates for the treatment of osteoporosis.

Alendronate should be the first choice of bisphosphonate for the treatment of osteoporosis in postmenopausal women, and the cheapest suitable preparation should be chosen. If severe adverse events (including gastric effects) occur and persist despite proper administration, and the patient has a combination of T-score, age and independent clinical risk factors that indicate further treatment is appropriate, risedronate may be considered.

If alendronate is not tolerated the choice of bisphosphonate is a clinical decision based on the individual requirements of the patient. Data suggest that risedronate may be associated with fewer upper GI AEs than alendronate, although some studies found no difference between the two.

Risedronate is the preferred option for the treatment of osteoporosis in the BNF, and its efficacy is supported by evidence from RCTs. Prospective, head-to-head trials (adequately powered to detect differences in gastric AEs) are required to definitively establish relative efficacy and safety.

No evidence could be located on the comparative gastric tolerability of ibandronate.