Which biphosphonate is the best to start osteoporosis treatment?

Speaking from my personal experience, starting with a bisphosphonate should be considered carefully. Bisphosphonates can improve bone density but prolonged use leads to more brittle bones. This is something I didn't know when started on Fosamax (alendronate) in 2018.

Bisphosphonates interrupt bone metabolism by suppressing osteoclast activity, even going so far as to kill off the osteoclast cells. For a time, this allows your osteoblasts to build new bone.

However, formation of new osteoblasts depends on signaling from osteoclasts and if osteoclasts are overly suppressed, new osteoblasts do not form and you stop building new bone.

Your existing bone gets older, drier, and more brittle over time. Our bones form micro-fractures as they age. The formation of these micro-fractures prompts the initiation of bone breakdown and replacement.

I was on Fosamax for over five years and experienced the outcome it was supposed to prevent: a vertebral compression fracture.

If I were starting over, I would agree to take Fosamax for a brief period of time to slow down bone breakdown during my early menopausal phase. At max, two years. I saw the best results during this time frame any ways.

As mentioned previously, new thinking is to use an anabolic first. There is also another good reason for doing this in that bisphosphonates when taken first will blunt the affect of an anabolic taken later.

Speaking from my personal experience, starting with a bisphosphonate should be considered carefully. Bisphosphonates can improve bone density but prolonged use leads to more brittle bones. This is something I didn't know when started on Fosamax (alendronate) in 2018.

Bisphosphonates interrupt bone metabolism by suppressing osteoclast activity, even going so far as to kill off the osteoclast cells. For a time, this allows your osteoblasts to build new bone.

However, formation of new osteoblasts depends on signaling from osteoclasts and if osteoclasts are overly suppressed, new osteoblasts do not form and you stop building new bone.

Your existing bone gets older, drier, and more brittle over time. Our bones form micro-fractures as they age. The formation of these micro-fractures prompts the initiation of bone breakdown and replacement.

I was on Fosamax for over five years and experienced the outcome it was supposed to prevent: a vertebral compression fracture.

If I were starting over, I would agree to take Fosamax for a brief period of time to slow down bone breakdown during my early menopausal phase. At max, two years. I saw the best results during this time frame any ways.

As mentioned previously, new thinking is to use an anabolic first. There is also another good reason for doing this in that bisphosphonates when taken first will blunt the affect of an anabolic taken later.

I have a document that I created with direct quotes from the sources. Here are some of the research links.

Severely Suppressed Bone Turnover: A Potential Complication of Alendronate Therapy
https://www.natap.org/2010/HIV/030910_01.htm
Bisphosphonates impair the onset of bone formation at remodeling sites
https://www.sciencedirect.com/science/article/pii/S8756328221000120
Bisphosphonates in osteoporosis
https://pmc.ncbi.nlm.nih.gov/articles/PMC3591825/
Long-Term Safety of Bisphosphonates
https://academic.oup.com/jcem/article-abstract/90/3/1897/2837115?redirectedFrom=fulltext
Fosamax Plus D: Package Insert / Prescribing Info (references how bone formation is reduced while taking it - see Mechanism of Action)
https://www.drugs.com/pro/fosamax-plus-d.html
Novel insights into the coupling of osteoclasts and resorption to bone formation
https://www.sciencedirect.com/science/article/pii/S1084952121002718
Advancement in the Treatment of Osteoporosis and the Effects on Bone Healing
https://www.mdpi.com/2077-0383/11/24/7477
Bisphosphonate Drug Holidays: Evidence From Clinical Trials and Real-World Studies
https://onlinelibrary.wiley.com/doi/10.1002/jbm4.10629
Long-term safety of bisphosphonates
https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=Long-Term+Safety+of+Bisphosphonates+susan+m+ott&btnG=