One hundred ninety seven postmenopausal women with osteoporosis were enrolled in a prospective, randomized, single-blind, controlled trial of 24 months' duration to compare the efficacy of Alendronate 10mg + Alfacalcidol 0.5μg + 500 mg calcium (group A), Alendronate 10mg + 500 mg Calcium (group B), Alfacalcidol 0.5 μg + 500mg calcium (group C), or Calcium 500 mg (group D), on bone mineral density and bone metabolism markers. Upon inclusion, the subjects were randomized to groups A, B, C and D according to a 1.5/2/1.5/1 scheme. BMD was measured at the lumbar spine (L2-L4) and the femur neck using dual energy x-ray absorptiometry (LUNAR DPX) at baseline and after 12 and 24 months. Biochemical markers of bone metabolism including osteocalcin, urinary calcium and urinary deoxypyridinoline, were collected at baseline, 6 month, 12 month, and 24 month. Data collection and statistical analyses were performed in a single-blind fashion. SPSS 10.0 and Statistica 7.0 statistical packages were used for data encoding and analysis. The 5% level was used as threshold for statistical significance. Upon inclusion and randomization, patients' characteristics (age, height, weight, time since menopause,) and study outcomes (osteocalcin, urinary calcium, deoxypyridinoline, and BMD values) were homogeneous between the four groups. At 2-years, and at the lumbar level, the highest significant gain in bone mass was seen for group A (+8.4%), followed by group B (+6.4%), and group C (+2.3%), while a significant decrease was seen among subjects from group D (-2.5%). A similar pattern was observed at the femoral neck level, with gains ranging from +5.3% for group A, +3.8% for group B, +1.2% (NS) for group C, and -6.4% for group D. Significant reductions of osteocalcin levels were observed among groups A (-4 %), B (-5.7%), and C (-1.7%). Urinary calcium was significantly increased in group C (+14%), while decreased in group B (-5.6%). Deoxypyridinoline significantly decreased among verum groups (A: -68%, B: -63.3%, C: -45%) and increased in the control group (+18.1%). Intergroup differences revealed a significantly higher gain in bone mass induced by treatments regimen A, B and C compared to D at both the femoral and lumbar levels, a higher decrease of osteocalcin levels in groups A and B versus D, similar variations of urinary calcium among the four groups, and a significantly higher reduction in deoxypyridinoline in group A, followed by B and C, versus D. The incidence of increased 24 h urinary calcaemia was similar between the four groups (p>0.06). No case of clinical hypercalciuria or hypercalcemia has been recorded. Gastrointestinal side effects occurred in 4 patients in Group A, and in 5 patients in Group B, which resulted in the termination of treatment. Data from this randomized controlled trial suggested a higher efficacy in increasing bone mineral density and a similar tolerance of combined therapy with Alendronate and Alfacalcidol compared to Alfacalcidol alone, and to Alendronate as a consistent trend. Importantly, the combined therapy resulted in lower rates of hypercalciuria, hypercalcemia, and hypocalcemia compared to monotherapies.