A 52 year old woman presents to her physician for a check-up. She is recovering from a wrist fracture after a fall. Dual energy x-ray absorptiometry of the hip had shown her to have osteoporosis. She became menopausal at age 50 and did not begin hormone replacement therapy because of a strong family history of breast cancer. She now fears a future hip fracture and would like to begin a bone loss prevention regime.Which of the following pharmaceutical agents is most appropriate for this patient?

Raloxifene is a selective estrogen receptor modulator that helps prevent osteoporosis by lessening bone resorption and reducing bone turnover. It lowers risk for veebral fractures by 40% to 50%. It is a bone-preserving alternative for women who prefer to avoid estrogen. Raloxifene does not cause breast pain and may lessen the risk for breast cancer in menopausal women. There is also a orable effect on LDL and cholesterol. Calcitonin nasal spray is an osteoclastic bone resorption inhibitor that modestly increases bone mineral density and reduces the incidence of veebral fracture. Although it is an estrogen alternative for bone preservation, its impact on hip fracture is not known. It is also lacks the anti-breast cancer propeies of raloxifene. Oral conjugated estrogen and transdermal estradiolare not the best choices, as this patient wants to avoid estrogen because of a strong family history of breast cancer. The route of administration of estrogen has been shown to have similar effects on bone preservation, even though the transdermal dosage is generally half that of the oral dosage. Breast cancer risk, however, is slightly increased with the unopposed higher dosage oral estrogen replacement. Tamoxifen , while indicated in the long-term care of breast cancer patients, is not alone useful for treatment or prevention of osteoporosis. Tamoxifen is an anti-estrogen agent that competes with estrogen for binding sites. Ref: Shoback D. (2013). Chapter 58. Osteoporosis & Glucocoicoid-Induced Osteoporosis. In J.B. Imboden, D.B. Hellmann, J.H. Stone (Eds), CURRENT Diagnosis & Treatment: Rheumatology, 3e.