What You Need to Know About Osteoporosis Medications

By Dr. John Neustadt

If you’ve been diagnosed with osteoporosis or osteopenia, you undoubtedly have been recommended a bone-building medication. 

Every doctor should aim to provide the best possible information so patients can make the best decision for themselves. A simple concept all healthcare providers are taught is informed consent. This means you, the patient, have been told the potential benefits, risks, and alternatives, and you’ve had an opportunity to get your questions answered. You deserve to have all your questions answered and concerns addressed. 

Prescribing a medication is a judgment call. The clinician is saying she believes (1) the medication is appropriate, (2) the medication will help you, and (3) the potential benefits outweigh the risks. This article, an excerpt from my book Fracture-Proof Your Bones, clarifies medication confusion and gives you questions to ask your doctor to ensure you get the best possible care. 

Lots of Options

In 2020, the global osteoporosis market was valued at over $13 billion. As you might imagine, with a big market, drug manufacturers have created many options to address the need. At least a dozen different drugs exist, which are divided into two broad categories. Those that reduce bone breakdown are called antiresorptive medications. Those that build bone are called anabolic medications. 

The antiresorptive medications include:

• • Bisphosphonates: alendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel), and zoledronic acid (Zometa). These are taken orally either daily or weekly, except for Zometa, which is given intravenously once a year.
  • Monoclonal antibody drugs: denosumab (Xgeva, Prolia). These are taken by an injection just under the skin (aka, a subcutaneous injection) every six months.
  • Natural hormones: calcitonin, estrogen. Calcitonin is taken daily as a nasal spray, while estrogen is typically taken daily by mouth or absorbed through the skin with a patch.
  • Estrogen modifiers: raloxifene (Evista), tamoxifen, toremifene (Fareston) change how estrogen acts in the body and are taken daily by mouth. 

The anabolic medications include: 

• • Parathyroid hormone (PTH): teriparatide (Forteo). This is taken by subcutaneous injection once a day. 
  • Monoclonal antibody: romosozumab (Evenity)—approved in 2017—is the first new drug in about 15 years and is taken by subcutaneous injection twice a month. 

What Caused Your Osteoporosis?

The most common osteoporosis diagnosis is postmenopausal osteoporosis. However, up to 30% of osteoporosis cases in postmenopausal women come from causes other than solely the drop in estrogen that comes with menopause.¹

A long list of medications cause osteoporosis. Chronic conditions, like Crohn’s disease, ulcerative colitis, and other gastrointestinal disorders, also damage bone and increase your fracture risk. If your doctor hasn’t reviewed your medications and other diagnoses and whether they can be causing your problem, ask for this evaluation. 

When your doctor recommends an osteoporosis medication, ask if it’s been shown in clinical trials to prevent fractures in people on the same medication (e.g., your antidepressant, acid-blocker, glucocorticoid, etc.) or with the same disease that created your osteoporosis. 

For example, in a clinical trial of women with early-stage breast cancer taking an aromatase inhibitor, denosumab reduced vertebral fracture risk by 68%, but bisphosphonates (oral and intravenous) had no benefit on fracture risk.² When medications are combined, they can also have the opposite effect and increase fracture risk. A meta-analysis of 57,259 people taking proton-pump inhibitors (PPIs) concluded that taking a bisphosphonate with a PPI increases fracture risk by 52% compared to people taking only a bisphosphonate.³

What’s Your Risk Tolerance?

If you decide a medication might help, you must also understand the potential risks. With medications, doctors are always balancing potential benefits with harms. Ask your doctor and pharmacist about the risks and the probability that you might experience any of them. 

For example, according to the FDA package insert for zoledronate, more than 25% of patients experience nausea, fatigue, anemia, bone pain, constipation, fever, vomiting, and shortness of breath. That may be an acceptable risk for you. But without knowing the risk, how can you make an informed decision? 

In a sad irony, oral bisphosphonates can create weaker bones and increase someone’s fracture risk.^4,5 When a bisphosphonate causes a fracture, it’s called an atypical fracture, and the risk increases the longer someone takes the medication. In one study that looked at this issue, the absolute risk for an atypical fracture was 0.1% after four or more years of taking an oral bisphosphonate.⁶ This means one person will experience this for every 1000 people taking the medication for four or more years. 

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) happens when your jawbone gets damaged and can’t heal. This often occurs during a dental procedure, like getting a tooth pulled. The exposed jawbone can become infected and begin to die. It’s a dangerous and complicated situation to treat. In people taking a bisphosphonate and have a dental procedure, the risk for BRONJ from oral bisphosphonates has been estimated at 4-8%.^7,8

To avoid this, dentists routinely ask patients to discontinue these medications before performing an invasive procedure. The American Academy of Clinical Endocrinology (AACE) recommends that patients get an oral exam before starting bisphosphonates or denosumab and delay treatment until the dental issues can be corrected.⁹

Can You Commit to Taking it Long Term?

To get the benefits, osteoporosis medications must be taken 70-80% of the time.¹⁰ Therefore, you have to be willing to commit to taking it consistently year after year. This is crucial. Because of side effects and how challenging it can be to take some of the medications, 50% of all patients who start an oral bisphosphonate stop refilling their prescriptions within a year, and 60% stop after two years.^11,12 For patients getting denosumab injections, one study estimated that 31% of patients are no longer taking the medication one year later, and by the third year 76% have stopped.¹³

You’ll need to take some medications daily, weekly, monthly, every six months, or annually. For example, if your prescription is for an oral bisphosphonate, you’ll need to take it on an empty stomach, daily or once a week, while standing up for at least 30 minutes to prevent damage to your esophagus (the tube from your mouth to your stomach). If you’re prescribed the parathyroid hormone medication Forteo, you’ll need to give yourself a daily injection under the skin in your thigh or abdomen. And if you take Prolia, it’s injected by your healthcare providers once every six months.

Ask your doctor how long you’ll be on the medication and what happens after you finish it. Frequently, they’ll want you to switch to a different drug. For example, once you finish Forteo, you’ll probably be recommended a bisphosphonate. You must understand the entire plan and ensure you’re comfortable with it. 

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