We now have more medications than ever before to help prevent bone fractures. And while no medication carries a 100 percent guarantee, studies show that some medications provide a 70 percent reduction in spine fractures and 40-50 percent reduction in hip and other fractures.
Selecting the best medication depends upon different factors. Let’s review the options.
Osteoporosis: Types of Medications
Available for more than two decades, we consider bisphosphonates a first line medication for both men and women. They are safe, effective, and tend to be inexpensive.
There are oral forms that include alendronate (Fosamax), risedronate (Actonel) and ibandronate (Boniva), taken weekly or monthly. The main side effect is irritation of the esophagus. Other rare side effects include muscle aches, rare eye issues, and bone pain.
Avoid such symptoms by taking these medications in a certain way: Take the medication first thing in the morning, either weekly or monthly, on an empty stomach and with a full glass of water. You may not lie down for the next 30-60 minutes. This gives the medication time to travel into the stomach. We recommend to not take any other food, pills, or drinks, except for water, during that time period. When people follow the instructions, they tolerate the medication well.
Some people cannot tolerate oral medications for different reasons, such as indigestion, inability to sit upright to take the medication correctly, esophageal issues, or the effects of a previous GI surgery. In these incidences, an IV or intravenous form of a bisphosphonate is a better choice. There is an IV form of ibandronate (Boniva), given every three months in an office.
In 2007, the FDA approved a once annual medication named zoledronic acid (Reclast) for fracture protection. Given in a vein, we bypass the GI tract and limit concerns for absorption or correct ingestion. Most people tolerate IV forms of these medications well. Some may develop an acute phase reaction or “flu-like” symptoms for one to two days after the infusion. Symptoms may include a low grade fever and/or muscle aches. Symptoms are usually mild. We ask that people proprerly hydrate for the infusion and perhaps take a Tylenol that morning to lessen the chance of symptoms occurring.
Selective Estrogen Receptor Modulators (SERM)
Approved for use in postmenopausal women, these medications work on the good estrogen receptors in the body and enhance bone health.The main medication in this class is raloxifene (Evista). Another SERM called basodoxifene comes in a combination pill with a form of estrogen.
These medications are in the same family as Tamoxifen, a treatment for breast cancer. Studies show that raloxifene reduces the risk of certain types of breast cancer. It is an oral medication, taken once per day.
Most women tolerate this medication well. It may cause hot flashes, so it is not a good choice for women experiencing any hot flash symptoms. A slight increased risk for blood clots make SERMS a poor choice for women who smoke, or who have any other risk factors for clots.
Research also shows that raloxifene reduces vertebral or spine fractures. There is no hip fracture prevention data available at this time.
Similar to the other medications discussed, Prolia works to stop the cells that break down bone (osteoclasts). It does this in a different way than bisphosphonates or SERMs. By stopping the cells that break down bone, it increases bone density and decreases fracture risk.
We administer Prolia under the skin every six months in an office. This medication became available in 2010, but the company that makes the medication has published ten years of data on its use.
Most people tolerate this medication very well. We tend to see good improvements in bone density. We do not recommend that a patient stop taking this medication abruptly as there are reports of patients experiencing spine fractures when then do. To prevent this, we prescribe a different medication when we stop Prolia.
There are two medications available that work on the cells that build bone (osteoblasts), rather than targeting bone breakdown. These medications are Teriparatide (Forteo) and Abaloparatide (Tymlos). Forteo has been available for use for more than ten years. Tymlos became available in 2017.
We prescribe these medications to people who have severe osteoporosis or who are at high risk for fracture. We also use these medications in people who may not have tolerated other treatment options. Both anabolic agents come in a pre-filled pen device. The patient administers a daily injection of either medication once per day for two years.
There is a reason we prescribe these medications for only two years. Teriparatide was also used on rats when researchers first studied it. Some rats received 30-50 times the amount given to humans. Researchers observed an increase in bone cancer or osteosarcoma. When they discovered this, they stopped the human study at two years. More than 10 years of published data show that teriparatide does not cause osteosarcoma in humans. Yet, we do only use it for two years and cannot use it if a person has other risk factors for osteosarcoma (such as previous radiation treatment for cancer, Paget’s disease of bone).
Most people tolerate these medications well. Uncommon side effects include dizziness, palpitations, and transient elevations in calcium levels. Because we only prescribe these medications for two years, a patient needs a different medication afterwards to maintain any gains made in bone density and fracture protection.
Medication selection and length of treatment
When selecting a medication, we decide not only which choice is best for the patient, but also how long do we want to treat for and what are we trying to achieve.
One key benefit of oral and IV bisphosphonates is that their effectiveness persists after we stop the medication. These medications work at the bone level and stay there for quite some time even when discontinued. This is helpful as our goal is not to necessarily give medications indefinitely. We like to perform a “drug holiday,” during which we stop medications, with fracture protection persisting for some time afterwards.
There are many factors to take into account when choosing a medication:
- Cost is always an issue. For people on Medicare, medications given in offices tend to go under Part B rather than Part D. This will then not have any effect on the “donut hole” that people have to think about for Medicare drug costs.
- How high a person’s risk for fracture is a big determining factor. For people at high risk, it may be best to start with an anabolic medication or other injectable.
- Other considerations include a patient’s kidney function and other medical issues.
The bottom line most of all is a person’s own preference. One most feel comfortable with and confident in the medication selected to be agreeable to take it regularly.
Fears over rare side effects
A big obstacle in the proper treatment of osteoporosis is the concern over very rare side effects. There are reports in the medical literature and media about patients taking anti-resorptive medications (medications that target the cells that break down bone) for a period of time and developing problems. The problems most concerning to patients are atypical femur fractures and osteonecrosis of the jaw.
Atypical femur fractures
Some people develop fractures in the middle of their femur (thigh bone) after the use of medications such as bisphosphonates and Denosumab. These fractures are very rare and the best estimate is about 1:10,000 patients.
Every research evaluation of these fractures reports patients with these fractures who never took any medication for osteoporosis. Some experts in the field believe these atypical fractures may be another type of osteoporotic fracture and some people are just more at risk. Because we have seen an association between long-term use of these medications and these atypical fractures, we do not give them indefinitely.
A patient and doctor should engage in regular conversation about how long to take a medication and the next best course of action. The benefit of these medications in preventing typical osteoporotic fractures far outweighs these rare risks. Any medication, including over-the-counter medications like aspirin, have potential side effects and risks.
Osteonecrosis of the Jaw
This is an extremely rare potential side effect of anti-resorptive medication use. We make this diagnosis when bone becomes exposed through the gum and does not heal.
This is more likely to occur in people receiving high doses of these medications for cancer treatments. Also, people with poor dentition and the use of chemotherapy or steroids are at higher risk. For patients who receive the doses of these medications that we use for osteoporosis, we estimate the incidence of this rare event at between 1:10,000 to 1:100,000. Considering the fact that osteoporotic fractures occur in 1 out of every 2 women over age 50 and 1 in every 5 men, the risks versus benefits is incomparable. We do always ask about dental procedures and regular exams while using these medications.
Osteoporotic fractures are unfortunately very common and can be devastating. There are several different safe and effective medications available to help reduce fracture risk. Experts in our field have declared that we are in a “crisis” in the treatment of osteoporosis. People decide not to take medications because of concerns of things that are very rare and in the meantime, put themselves at risk for harm from fractures.