Boniva vs. Fosamax: Differences, similarities, and which is better for you

Drug overview & main differences | Conditions treated | Efficacy | Insurance coverage and cost comparison | Side effects | Drug interactions | Warnings | FAQ

Boniva and Fosamax are two prescription medications used in the treatment of osteoporosis. Osteoporosis is a disease of the bones. It occurs when bone mineral density or bone mass decreases, or when the quality of the bone deteriorates. When the quality of bone decreases, individuals are at an increased risk of bone fractures, or broken bones. These fractures may include hip fractures, vertebral fractures, and fractures to the femur and thigh bone. 

There are many things that can decrease your likelihood of developing osteoporosis. These include regular physical activity and exercise, minimizing alcohol intake, refraining from tobacco use, and eating a diet rich in vitamin D and calcium. If your doctor determines you need prescription treatment for osteoporosis, they may choose Boniva and Fosamax, which belong to a class of drugs known as bisphosphonates. There are other treatment options for osteoporosis, which include Evista (raloxifene), Forteo (Teriparatide), Prolia (denosumab), calcitonin, and estrogen therapy.

What are the main differences between Boniva and Fosamax?

Boniva (ibandronate) is a prescription drug that is classified as a bisphosphonate. Bisphosphonates work by inhibiting osteoclast-mediated bone resorption. They do not inhibit bone formation. Second-generation bisphosphonates, such as Fosamax, are more potent inhibitors of osteoclasts than those of the first generation, such as Didronel (etidronate). Other second-generation bisphosphonates include Actonel (risedronate), Fosamax (alendronate), Aredia (pamidronate), and Reclast (zoledronic acid). Boniva is available in a single strength oral tablet of 150 mg. Boniva in its oral form is taken once monthly. Boniva is also available as a solution for injection in a concentration of 3 mg/3 ml.

Fosamax (alendronate) is a prescription drug that is also a second-generation bisphosphonate. Fosamax is available in oral tablets in strengths of 5 mg, 10 mg, 35 mg, and 70 mg. It is also available in a 70 mg/75 ml oral solution. The 5 mg and 10 mg doses are intended to be once-daily doses. The 35 mg and 70 mg are once-weekly doses.

Main differences between Boniva and Fosamax
	Boniva	Fosamax
Drug class	Bisphosphonates	Bisphosphonates
Brand/generic status	Brand and generic available	Brand and generic available
What is the generic name?	Ibandronate	Alendronate
What form(s) does the drug come in?	Oral tablets and solution for injection	Oral tablets and oral solution
What is the standard dosage?	150 mg once monthly	70 mg once weekly
How long is the typical treatment?	Long term	Long term
Who typically uses the medication?	Adults	Adults

Conditions treated by Boniva and Fosamax

Boniva and Fosamax are used in both the treatment and prevention of osteoporosis. For Fosamax, this includes postmenopausal and corticosteroid-induced osteoporosis. Boniva is approved for use in postmenopausal, but its use in corticosteroid-induced osteoporosis is off-label. Off-label refers to the use of a drug for an indication for which it has not been approved by the Food and Drug Administration (FDA). Fosamax is also approved in the treatment of Paget’s disease, a condition where bones grow larger and weaker than normal. Boniva is also used for this purpose off-label.

Condition	Boniva	Fosamax
Postmenopausal osteoporosis treatment	Yes	Yes
Corticosteroid-induced osteoporosis treatment	Off-label	Yes
Postmenopausal osteoporosis prophylaxis	Yes	Yes
Corticosteroid-induced osteoporosis prophylaxis	Off-label	Yes
Paget’s disease	Off-label	Yes
Hypercalcemia of malignancy	Off-label	Off-label
Adverse skeletal events due to bone metastases	Off-label	No

Is Boniva or Fosamax more effective?

The Monthly Oral Therapy With Ibandronate For Osteoporosis Prevention trial study, otherwise known as the MOTION trial, included over 1,700 postmenopausal women aged 55 to 84. The study compared once-monthly Boniva to once weekly Fosamax with regard to their ability to increase bone mass density (BMD) at the lumbar spine and in the total hip. The results showed that once monthly Boniva is non-inferior to Fosamax with regards to this endpoint. The reduction in bone turnover and gastrointestinal tolerability were also comparable. 

The Boniva Alendronate Trial in Osteoporosis, or BALTO trial, evaluated patients’ preference between the once weekly Fosamax and the once monthly Boniva. The results of this randomized, cross-over trial found that significantly more patients prefer the once monthly regimen, with 66.1% preferring Boniva as compared to 26.5% preferring Fosamax. The remainder indicated no preference for one regimen over the other. 

This information is not intended to be medical advice. Only your physician can determine which treatment option is most appropriate for your condition. 

Coverage and cost comparison of Boniva vs. Fosamax

Boniva is a prescription medication that is typically covered by commercial and Medicare insurance plans. Without insurance, the once monthly regimen could cost you $258 for one tablet. With a coupon from SingleCare, generic Boniva cost could be as low as $22.

Fosamax is a prescription medication that is covered by both commercial and Medicare insurance plans. A one month supply of Fosamax may cost you as much as $102 without insurance. A SingleCare coupon for generic Fosamax can reduce the cost to less than $20.

	Boniva	Fosamax
Typically covered by insurance?	Yes	Yes
Typically covered by Medicare Part D?	Yes	Yes
Quantity	1, 150 mg tablet	4, 70 mg tablets
Typical Medicare copay	<$10	<$10
SingleCare cost	$22-$98	$16-$39

Common side effects of Boniva vs. Fosamax

Bisphosphonates are known for their tendency to cause gastrointestinal side effects such as abdominal pain, nausea, diarrhea, and constipation. Patients who have a history of gastrointestinal disease may not be candidates for bisphosphonate therapy because they are at a high risk of experiencing these side effects while on bisphosphonate therapy. These reactions are sometimes severe enough to require hospitalization.

Fosamax and Boniva are both known to cause musculoskeletal pains in the bones, muscles, and joints. 

Boniva has been shown to be associated with increased blood pressure as well as insomnia, or difficulty sleeping.

The following chart is not meant to be an all-inclusive list of possible adverse events related to Fosamax and Boniva. Please consult your healthcare provider for a complete list.

	Fosamax		Boniva
Side effect	Applicable?	Frequency	Applicable?	Frequency
Abdominal pain	Yes	6.6%	Yes	7.8%
Nausea	Yes	3.6%	Yes	5.1%
Dyspepsia	Yes	3.6%	Yes	5.6%
Constipation	Yes	3.1%	Yes	4.0%
Diarrhea	Yes	3.1%	Yes	5.1%
Flatulence	Yes	2.6%	No	N/A
Acid regurgitation	Yes	2.0%	No	N/A
Esophageal ulcer	Yes	1.5%	No	N/A
Vomiting	Yes	1.0%	No	N/A
Dysphagia	Yes	1.0%	No	N/A
Abdominal distention	Yes	1.0%	No	N/A
Gastritis	Yes	0.5%	Yes	2%
Musculoskeletal pain	Yes	4.1%	Yes	4.5%
Headache	Yes	2.6%	No	N/A
Taste perversion	Yes	0.5%	No	N/A
Hypertension	No	N/A	Yes	6.3%
Myalgia	No	N/A	Yes	2.0%
Rash	No	N/A	Yes	2.3%
Insomnia	No	N/A	Yes	2.0%

Source: Fosamax (DailyMed) Boniva (DailyMed)

Drug interactions of Boniva vs. Fosamax

When Boniva and Fosamax are given with calcium containing supplements or antacids, the calcium may interfere with the absorption of the Fosamax. Many osteoporosis patients need to take a calcium supplement, therefore it is recommended that you wait a minimum of 30 minutes after taking Fosamax to take calcium or any other oral medications.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are associated on their own with gastrointestinal side effects similar to bisphosphonates. It is not recommended to take consistent doses of NSAIDs while taking bisphosphonates.

There is some evidence that giving bisphosphonates with H2-blockers, a form of stomach acid reducers used to treat heartburn, increases the bioavailability of the bisphosphonate drug.

This chart does not list every known drug interaction. Please consult your healthcare professional for a complete list.

Drug	Drug class	Fosamax	Boniva
Calcium Aluminum Magnesium Iron	Multivalent cation supplements and antacids	Yes	Yes
Aspirin Ibuprofen Naproxen Diclofenac Ketorolac Meloxicam Celecoxib	Nonsteroidal Anti-inflammatory Drugs (NSAIDS)	Yes	Yes
Famotidine Ranitidine	H2-blockers	Yes	Yes

Warnings of Boniva and Fosamax

Dental extractions while on bisphosphonate therapy may increase the risk of developing osteonecrosis of the jaw (ONJ), or the gradual death of the jawbone. Prior to starting bisphosphonate therapy, patients should have a dental examination and consider doing any preventive or corrective dental procedures prior to beginning therapy.

Patients who have existing esophageal conditions such as Barrett’s esophagus, dysphagia, or ulcers may have their condition further aggravated by bisphosphonates. Because of their tendency to cause irritation to the mucosa of the esophagus, bisphosphonates should be taken first thing in the morning with a small glass of water. Other medications, drinks, and food should be avoided for at least 30 minutes, but ideally for two hours. Patients should remain upright for at least 30 minutes after taking their dose. They should not lay down. These precautions will minimize esophageal irritation.

Patients who have low calcium levels, or hypocalcemia, should take the necessary steps to correct their calcium levels prior to starting bisphosphonate therapy. Patients may continue calcium therapy once they start bisphosphonates as long as they follow the guidelines to separate their calcium dose from the bisphosphonate.

Fosamax and Boniva should be used with caution in patients with impaired renal function or kidney disease. Renal function should be monitored because decreased renal function means you will not be able to clear the drug from your body as efficiently and the drug can accumulate in your body.

Frequently asked questions about Boniva vs. Fosamax

What is Boniva?

Boniva is a prescription medication in a class called bisphosphonates. It is used to treat and prevent osteoporosis. Boniva is available as an intravenous solution as well as a once monthly oral tablet.

What is Fosamax?

Fosamax is also a prescription medication in the class of drugs known as bisphosphonates. It is used in the treatment and prevention of osteoporosis. Fosamax is available in once daily oral tablets, once weekly oral tablets, and an oral solution.

Are Boniva and Fosamax the same?

Boniva and Fosamax are second-generation bisphosphonates, but they are not exactly the same. Their biggest difference is in how they are dosed. Boniva can be given once monthly, while Fosamax can be given once daily or once weekly.

Is Boniva or Fosamax better?

Studies have shown Boniva and Fosamax to have very similar clinical outcomes regarding bone health, however, at least one study has shown that an overwhelming majority of patients prefer the once monthly dosing regimen of Boniva.

Can I use Boniva or Fosamax while pregnant?

Neither Boniva or Fosamax have been studied in pregnant women. Their use should be avoided in pregnant women to avoid harm to the fetus.

Can I use Boniva or Fosamax with alcohol?

Alcohol and all liquids should be avoided for a period of time after taking Boniva or Fosamax to avoid esophageal irritation. Consistent alcohol consumption is associated with higher risks of osteoporosis, and therefore it is a good idea to limit consumption.

What is the best and safest drug for osteoporosis?

The National Osteoporosis Foundation provides guidelines for the treatment of osteoporosis. Bisphosphonates such as Fosamax, Boniva, Reclast, and Actonel are considered first-line prescription treatments along with other recommendations such as calcium supplementation and exercise.

Does Boniva increase bone density?

Boniva is associated with significant increases in bone mineral density (BMD). This reduces the risk of fractures in osteoporosis patients.

Should you take calcium with Boniva?

You should not take calcium at the same time as Boniva, but you can take calcium for bone loss while on Boniva therapy. You must wait at least 30 minutes after your bisphosphonate dose before taking your calcium supplement.