Medications to prevent and manage osteoporosis

There are a number of medications available for the prevention and management of osteoporosis. If you have osteoporosis or low bone density, please discuss each of these medications carefully with your health care provider.

REMEMBER: All medications require adequate calcium, vitamin D and exercise to work best.

Bisphosphonates

Bisphosphonates are used in the prevention and treatment of postmenopausal osteoporosis. They can help prevent fractures of the spine, hip, and wrist in people with osteoporosis and prevent bone loss for men and women taking steroids. Bisphosphonates work by slowing cells that break down bone (osteoclasts) allowing cells that build bone (osteoblasts) more time to work and reduce the imbalance. Actonel® and Fosamax® have also been approved by the FDA for the treatment of osteoporosis in men. Etidronate (Didronel®) was the first bisphosphonate used clinically in the United States and has been approved for the treatment of Paget’s disease, but not for osteoporosis.

Brands

Weekly dosing

• Actonel® (risedronate)
• Fosamax® (alendronate)
• Generic Fosamax (alendronate) approved by FDA in 2008
• Boniva® (ibandronate)

Monthly dosing

• Actonel® (risedronate)
• Boniva® (ibandronate)

Yearly dosing

• Reclast® (zolendronic acid) infusion

Side effects of bisphosphonates may include muscle aches, joint aches, stomach upset or heartburn.

In a small number of cases, osteonecrosis of the jaw (ONJ) has been reported. For more information on osteonecrosis of the jaw.

There are a small number of case reports about unusual fractures occurring in the mid-thigh of patients on bisphosphonates. Learn more about femur fractures and the risks of drug use in BONESENSE What to Make of Bisphosphonate Drug Risk.

IMPORTANT: FOLLOW THE INSTRUCTIONS FOR TAKING A BISPHOSPHONATE: Bisphosphonates are difficult for your stomach to absorb. So for maximum effectiveness, follow these instructions:

• Take first thing in the morning on an empty stomach.
• Take the pill with a FULL 8 OZ glass of water. Do not use orange juice, coffee or any other beverage to take this medication.

• Do not eat food or drink other liquids for at least 30 minutes. Remain sitting or standing up (do not lie down) for 30 minutes after taking the medication.

Hormone Therapy (HT)

For years, hormone therapy (HT) was considered a panacea for women adjusting to the changes of menopause and for preventive health. Despite a clear benefit to bone, HT may present other risks for some women. Estrogen remains indicated for the prevention of osteoporosis, but not for the treatment of osteoporosis. The decision to take HT is individual and complex.

The current recommendations are to take the lowest dose possible for the shortest period of time for menopausal symptoms. Talk to your doctor about risks and benefits including long-term effects. It is important to evaluate the pros and cons on an annual basis with your doctor. The North American Menopause Society has more information about hormone therapy.

HT is administered in several forms including oral or transdermal, gels and lotions.

Side effects: HT is associated with a slightly increased risk of breast cancer, stroke, and deep vein thrombosis.

Brands: Premarin®, Estrace®, Ogen®, Cenestin®, Climara®, Vivelle-Dot®, Menostar®, and others.

Parathyroid Hormone (PTH)

Parathyroid Hormone is an anabolic treatment for osteoporosis that stimulates new bone growth and reduces fracture risk. PTH is generally reserved for individuals with severe osteoporosis. Studies demonstrated significant increases in bone mineral density and large decreases in fractures. PTH is a daily injection like insulin that is prescribed for 12-24 months. FORTEO is approved for men and postmenopausal women with osteoporosis who are at high risk for fractures.

Brand: Fortéo

Side effects: May include dizziness and leg cramps.

Denosumab

Denasumab is “first in its class” as a biologic for the treatment of postmenopausal osteoporosis and given by injection every six months. It works by decreasing the activity of osteoclasts, the cells that break down bone, helping the bone building cells increase bone mass and strength.

The drug is being recommended for women with osteoporosis and high fracture risk, which includes patients who have had an osteoporotic fracture, have several risk factors, or have not responded to other treatments.

Brand: Prolia

Side effects:May include back and muscle pain, pain in the extremities, elevation of  lipids in the blood, and bladder infection.

Selective Estrogen Receptor Modulators (SERMs)

SERMs, often called designer estrogens, are a family of drugs made in a laboratory. They have some effects similar to estrogen on bone, cholesterol and other blood fats. SERMs decrease the effects of estrogen on certain tissues like the breast and uterus, and may be used with people who are at risk for developing these cancers. SERMs may also reduce the risk of breast cancer and lower your cholesterol. Research is currently being done to better understand these effects.

One SERM, Evista® (raloxifene), has been approved for the prevention and treatment of osteoporosis. Evista® has been shown to help prevent bone loss in the hip and spine and decrease spine fractures.

There are many promising new SERMS in clinical trials for the prevention and treatment of osteoporosis.

Evista® is available as a pill.

Brand: Evista®

Side effects: May include hot flashes, leg cramps and blood clots. SERMs normally do not cause bloating, breast tenderness, or bleeding from the uterus.

Calcitonin

Calcitonin is a hormone normally found in the human body that helps with bone metabolism and calcium regulation. It can slow bone loss in the spine and increase spinal bone density and may also help reduce the risk of spinal fractures or help decrease the pain of these fractures. It has not been shown to prevent bone loss or fracture in other parts of the body.

Calcitonin is given as a nasal spray or as an injection.

Brand: Miacalcin

Side effects: May include a runny nose with the nasal spray or an allergic reaction or other effects with the injectable form.