Raloxifene is known to be associated with a risk for blood clots, and the development of a thrombosis while on raloxifene therapy is considered by many to be a contraindication for further use. So, this adverse effect regrettably requires a change in an effective therapy. In this setting, the first option would be to continue treatment with alendronate while maximizing vitamin D and calcium intake, as once a patient has stabilized, on average, raloxifene has relatively little to add to the effects of alendronate. The target dose of calcium should be in the range of 1,500 mg per day and vitamin D approximately 1,000 IU. As part of this strategy, it's prudent to ensure that the individual can metabolize vitamin D to the biologically relevant molecule, and this can be assessed with a blood test for 1,25-dihydroxyvitamin D3, the active metabolite.

Should this approach not yield good results, there are two options. Calcitonin is useful for acute issues, but a better long-term candidate would be parathyroid hormone, given as an injection. This has been associated with new bone deposition. In this case, alendronate should be stopped during the parathyroid hormone therapy, which is usually given for 18 months. Afterwards, alendronate treatment should be reinstituted. The caveat is that parathyroid hormone costs roughly $800 per month, and although some private insurers will pay for this patient, who lives in Ontario, the Ontario Drug Benefit Plan, at this time, does not.