Good to the Bone: Which Osteoporosis Medication is Right for You?

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By Zubair Ilyas, MD and Pauline Camacho, MD, FACE
osteoporosis consultation

Osteoporosis is a disease state where decreased bone density increases the risk of fractures. It is frequently seen in post-menopausal women but can affect anyone. Generally there are no warning signs until there is a broken bone, which is why it is important to talk to your doctor about being screened for it.

Activity

The old adage of “use it or lose it” applies to bones, which respond very well to activity and exercise. Getting at least 30 minutes of vigorous activity five times weekly, as recommended by the American Heart Association, has heart benefits and can also be an important stimulus to your bones as well, as a signal to help strengthen them. Ask your doctor about the extent of vigorous activity and weight bearing exercises you can perform.

Vitamin D and Calcium

The first step in keeping your bones healthy is to make sure to get enough vitamin D and calcium; 1000 - 2000 units of vitamin D3 or cholecalciferol and 1000 – 1200 mg of calcium daily is recommended. You can get vitamin D is when your skin is exposed to sunlight, but also from certain foods such as cod liver oil, egg yoks and sardines, and/or supplements. Foods that contain calcium include dairy products, such as milk, cheese, or yogurt, leafy greens and legumes (be sure to check the nutrition labels for nutritional content). If you think you don’t get enough calcium in your diet, you can supplement with over-the-counter calcium-containing tablets.

An active lifestyle and getting enough vitamin D and calcium are important for everyone's bone health, even if you don't have osteoporosis. However, if you have significant bone loss, you may benefit from one of the following treatment options.

Anti-resorptive Agents

There are several osteoporosis drugs that fall under the category of anti-resorptive agents. They prevent your bones from losing further bone density, may help strengthen them and have been shown to decrease the risk for fractures.

Bisphosphonates

The most common class of medications used for osteoporosis is the bisphosphonates, which are still considered first-line therapy. These include alendronate (weekly), risedronate (weekly or monthly), ibandronate (monthly), and zoledronic acid (intravenous infusion yearly). In general, the oral formulations are used for 5 years, or up to 10 years in high risk individuals, followed by a pause in usage. Intravenous zolendronic acid is typically used for three years, or up to six years in high risk individuals, followed by a pause in usage. This pause is termed a “drug holiday” and allows for the bone to be revitalized. Your doctor will continue to monitor you during this time and may need to start you back on therapy at a later date if indicated. You may also need to be on treatment for longer than these stated times if your osteoporosis is advanced.

Bisphosphonates are not recommended for people with severe kidney disease or low blood calcium. Side effects may include bone, joint or muscle pain. Tablets taken by mouth may cause heartburn, nausea or difficulty swallowing. A small number of people receiving an intravenous infusion may experience flu-like symptoms which resolve after 2-3 days and usually do not happen with future infusions. Rare side effects include osteonecrosis of the jaw, which may occur when the jaw bone is exposed and starved from blood after a tooth extraction, and unusual fractures of the upper thigh bone (femur) in people taking bisphosphonates for long periods of time.

"Maintaining an active lifestyle and getting enough vitamin D and calcium are important first steps for your bone health."

Denosumab

This is a newer treatment option under the anti-resorptive class and is being used more often in practice today. It is administered as a shot under the skin every six months. Treatment with denosumab is continued without a drug holiday and it has been shown to be efficacious for up to ten years. However, in cases when discontinuation is decided, transition to a different agent is recommended to prevent the rebound of bone loss. This is because if treatment with denosumab is stopped, the risk for breaking bones is increased.

Denosumab is not recommended for people with low blood calcium. Side effects may include low blood calcium. Rare side effects include osteonecrosis of the jaw (see above) and unusual thigh bone fractures.

Anabolic Agents

Teriparatide and abaloparatide are newer agents being used to treat osteoporosis. They are once-a-day shots under the skin. If you qualify for treatment, you or a family member will need to learn how to administer these shots at home. Currently, treatment with these agents is limited to two years. They are known to build bone, hence their classification under anabolic agents. However, you can lose bone very quickly upon completion of therapy. This is why after stopping an anabolic agent, an anti-resorptive agent will need to be started immediately.

Treatment is not advised in some cases, such as in patients with a history of cancer, radiation or Paget's disease. This is because in animal studies, there have been cases of bone cancer. Other side effects include an elevated calcium level and kidney stones.

Hormone Replacement Therapy (HRT)

Hormone replacement therapy (HRT) includes taking estrogen (a hormone typically made by your ovaries) and if you never had a hysterectomy, progesterone. It is less commonly used nowadays. HRT has been shown to protect against bone loss in postmenopausal women, as well as provide relief for hot flashes and night sweats. Risks of HRT include increased risk for uterine cancer, blood clots and stroke.

Selective Estrogen Receptor Modulator (SERM)

SERMs are considered another form of HRT. They are a class of drugs that act like estrogen in your body, specifically on the bones. Raloxifene is a commonly used SERM in postmenopausal women. It may also be used as a treatment option for breast cancer. Similarly to HRT, side effects can include blood clots and stroke.

Calcitonin

Calcitonin is a hormone that regulates calcium and phosphate levels in the blood and decreases bone breakdown. It is taken either as a daily nasal spray or as a shot under the skin. Although it decreases bone breakdown, studies have not shown any benefit in preventing fractures and is the least potent of the available treatment options.

So, what’s the right treatment for you?

Maintaining an active lifestyle and getting enough vitamin D and calcium are important first steps for your bone health. But if you have osteoporosis, your bones will benefit from one of the treatment options listed above. Keep in mind there is no one-size-fits-all treatment option. Once you understand your options and their benefits and risks, then you can make an informed decision. Talk to your doctor to see which options would be the best for you.