The Hows and Whys of Osteoporosis Medications
|Class and Drug||Brand Name||Form||Frequency||Gender|
|Alendronate||Fosamax®, Fosamax Plus D™||Oral (tablet, solution)||Daily/Weekly||Women & Men
|Alendronate||Binosto®||Oral (effervescent tablet)||Weekly||Women & Men|
|Ibandronate||Boniva®||Intravenous (IV) injection||Every 3 months||Women|
|Risedronate||Actonel®||Oral (tablet)||Daily/Weekly/Twice Monthly/Monthly||Women & Men|
|Zoledronic Acid||Reclast®||Intravenous (IV) infusion||One Time per Year/Once every two years||Women & Men
RANK ligand (RANKL) inhibitor
|Denosumab||Prolia™||Injection||Every 6 Months||Women & Men
|Calcitonin||Fortical®, Miacalcin®||Nasal spray||Daily||Women|
Estrogen* (Hormone Therapy)
|Estrogen||Multiple Brands||Oral (tablet)||Daily||Women|
|Estrogen||Multiple Brands||Transdermal (skin patch)||Twice Weekly/Weekly||Women|
Tissue Specific Estrogen Complex (TSEC)
|Romosozumab-aqqg||Evenity||Injection||2 injections once monthly for 12 months||Women|
Parathyroid Hormone (PTH) Analog
|Teriparatide||Forteo®||Injection||Daily||Women & Men
Parathyroid Hormone-Related Protein (PTHrp) Analog
|*Estrogen is also available in other preparations including a vaginal ring, cream, by injection and as an oral tablet taken sublingually (under the tongue). The vaginal preparations do not provide significant bone protection.|
What Causes Fragile Bones in Older People?
Your skeleton is an active vital organ. It keeps you healthy through a constant process of repair, renewal, and mineral release. This process is called remodeling.The bone remodeling cycle consists of two distinct stages: (1) bone resorption (breakdown and removal) and (2) bone formation (generation of new bone). During resorption, cells on the bone’s surface called osteoclasts dissolve bone tissue, releasing it into the bloodstream and leaving behind tiny pits, or cavities. Then, during formation, cells called osteoblasts fill these cavities with new bone tissue. In normal bone, resorption and formation are in lock step, with one matching the other.
As we age, the remodeling process can become unbalanced. More old bone gets removed than new bone gets created. Over time, this leaves bones weaker and more likely to break. A variety of circumstances can cause unbalanced bone remodeling including hormonal changes, certain medications, prolonged inactivity, as well as other diseases.
Bone can also be resorbed to replace essential minerals missing in the bloodstream. This happens when there is not enough calcium in the diet. The result in all of these scenarios is the same: slow but steady weakening of bones that can eventually lead to osteoporosis and broken bones (also called fractures).
How Can Osteoporosis Medicine Help?
The goal of osteoporosis therapy is to try to restore the balance of resorption and formation. It can be done by slowing resorption through use of antiresorptive medication or by promoting bone formation using anabolic medication. By doing so, these therapies lower the risk for fractures, which is the goal of treatment.
Special Note: Information provided here about FDA-approved osteoporosis medicines is intended solely for general information and should NOT be relied upon for any particular diagnosis or treatment. This information does not imply an endorsement by BHOF of any medicine or manufacturer.For more detailed information on the actions, administration, and possible side effects for each of the medicines discussed here, please consult the package insert, available online and at pharmacies.
Medications to Prevent Fragility Fractures
There are many medications available to treat osteoporosis and reduce the risk of fracture. They fall into two basic categories: antiresorptives and anabolics. Antiresorptive drugs include bisphosphonates (alendronate, ibandronate, risedronate, zoledronic acid), denosumab, calcitonin, estrogen/estrogen-progestin, an estrogen agonist/antagonist (raloxifene), and a tissue specific estrogen complex (estrogen/bazedoxifene). Antiresorptive drugs work by slowing the resorption or breakdown part of the remodeling cycle. Anabolics work by stimulating the formation part of the remodeling process. More bone is formed than is taken away. The result is stronger bone that is less likely to break. Teriparatide, a parathyroid hormone analog, abaloparatide, a parathyroid hormone-related protein analog, and romosozumab-aqqg, a sclerostin inhibitor, are the FDA-approved anabolic medicines available at this time.
All of these drugs reduce the likelihood of having fragility fractures. They come in a range of formulations, from daily tablets to yearly intravenous infusions. There is no best medication for everyone. The one that works for you depends on many factors. Your health history and preferences are considerations. Discuss it with your health care provider.
- Alendronate Sodium or Alendronate Sodium plus Vitamin D3 (Fosamax®, Fosamax Plus D and Binosto®)
- Ibandronate Sodium (Boniva®)
- Risedronate Sodium (Actonel®and Atelvia™)
- Zoledronic Acid (Reclast®)
- Denosumab (Prolia®)
- Calcitonin-Salmon (Fortical®and Miacalcin®)
- Menopausal Hormone Therapy (MHT) (Multiple brands available)
- Raloxifene (Evista®)
- Tissue-Selective Estrogen Complex: Conjugated Estrogens/Bazedoxifene (Duavee®)
- Teriparatide (Parathyroid Hormone analog) (PTH) (1-34) (Forteo®)
- Abaloparatide (Parathyroid Hormone Related-Protein analog, (PTHrP) (1-34) (Tymlos®)
- Romosozumab-aqqg (Evenity®)
It Can’t Work If You Don’t Take It
Like any medication, osteoporosis drugs can only work if they are taken exactly as prescribed. With many health conditions, it is easy to remember to take your medicine because when you don’t, you feel bad. Your blood pressure goes up or some other obvious problem results. That doesn’t happen with osteoporosis. Without bone density testing, you can’t even tell you have osteoporosis until you break a bone. By the same token, when you take osteoporosis medicine, you can’t feel your bones getting stronger. Youmightnotice that you haven’t broken a bone; however, if you are like most people, you won’t notice something that doesn’thappen.
The important thing is to take your medicine and take it consistently. If you have any trouble following your treatment plan, or if you have concerns about side effects, talk to your health care provider. Don’t suffer in silence. It happens to many people. Your provider can help you find something that works for you. There are lots of different options, one is sure to fit your needs.
How Can You Tell If the Medicine Is Working?
So, how can you tell your medicine is working? With antiresorptive medicines, the goal of treatment is to prevent further bone loss and reduce the risk of fractures. You know the drug is working when your bone density stays the same or improves and you have no additional broken bones. With anabolic medicine, the goal of treatment is to rebuild bone, increase bone mass, repair microscopic defects in bone, and reduce the risk of fractures. You know it’s working when your bone mineral density improves and you have no additional broken bones.
Your healthcare provider will keep track of your progress by periodically testing your bone density and sometimes checking your blood and urine.
How Long to Take Osteoporosis Medications?
Romosozumab-aqqg, Teriparatide and Abaloparatide are the only drugs for osteoporosis that have a defined treatment length. The FDA recommends that treatment be limited to no more than 18 months or two years. There is a great deal of variability in terms of ideal treatment duration for other medications.
Some drugs, like raloxifene and denosumab, leave the body quickly. Their effects generally disappear after one stops taking them. Some drugs, like bisphosphonates, stay in your bones after you stop taking them — some longer (alendronate, zoledronic acid) than others (risedronate, ibandronate). They may continue to work and offer protection even after one stops taking them. The most effective regimen and duration depends on the individual drug, the individual patient, and her/his level of fracture risk.
What Is a Bisphosphonate Holiday?
When a patient responds well to bisphosphonate therapy, many healthcare providers will consider a “bisphosphonate drug holiday” during which the patient takes a break from treatment. It’s important to recognize this is temporary, like a vacation, not permanent, like retirement. Eventually, lingering bisphosphonate benefits wear off and fracture risk rises. Drug holidays must be closely monitored so that treatment can be restarted when needed to avoid fractures. Also, only bisphosphonate drugs stay in the body long enough for a drug holiday to work. Other osteoporosis drugs lose their effect rapidly and must be taken continuously to protect bone, or if they are stopped, a different drug should be started in their place. Many healthcare providers consider a bisphosphonate drug holiday after five years of treatment if bone density is stable and no fractures have occurred.
Weighing Risks and Benefits of Anti-Fracture Medications
You may have heard about sudden thigh bone fractures in people who are taking antiresorptive drugs, namely bisphosphonates and denosumab. This rareside effect is called an atypical femur fracture (AFF). An even less common side effect reported in people taking bisphosphonates and denosumab is a nonhealing area in the jawbone called osteonecrosis of the jaw (ONJ). Although it has been seen in people on lower doses for shorter periods, ONJ is almost always seen in people being treated with high doses of these medications for cancer, frequently following oral surgery. Good dental care is a reasonable precaution for anyone taking antiresorptive medication for osteoporosis.
At the doses used for osteoporosis, AFF and ONJ are very rare. On the other hand, fragility fractures from osteoporosis are very common. Out of 1,000 women, 500 will suffer a fracture during their lifetime unless they get treatment for osteoporosis.
Don’t Forget Your Calcium and Vitamin D
Whatever medication you are prescribed to protect your bones, it won’t work without enough calcium and vitamin D. Calcium tablets are good for filling in when you can’t get enough in your diet, but it is always better to get calcium from food. Because there are not as many food sources of vitamin D, supplements are generally recommended for most people.
When You Prevent Falls, You Prevent Fractures
Falls are the leading cause of broken bones in older people. If you prevent falls, you prevent fractures. Many factors contribute to falling. These include bad eyesight, balance problems, sedating drugs, weak legs, dizziness, and slow reflexes. A lot can be done to reduce the risk for falls. Some suggestions include the following: Safety proof your home. Install grab bars in bathrooms. Get rid of tripping hazards. Put in brighter light bulbs. Keep your glasses prescription up to date. Exercise for muscle strengthening and to improve balance. Let your healthcare provider know right away if you are feeling dizzy. The bottom line is that you should stay as active as possible to build endurance and agility.
Taking Medicines Safely
Many diseases and medical treatments can contribute to broken bones in older people, either by causing bone loss or by causing falls. When visiting your healthcare provider, go over all of the medicine prescribed to you. Ask if anything you take can cause you to lose bone or make you dizzy or light headed. Most of the time, simple changes in scheduling or medication type can eliminate problems that could easily lead to devastating falls and broken bones.
Older Adults and Medications
Older people as a group tend to have more long-term, chronic illnesses such as arthritis, diabetes, high blood pressure and heart disease, than any other age group. Because they may have a number of health problems or issues at the same time, it is common for older people to take many different drugs.
Understanding Your Medication
Try to find out as much as you can about any medication you are prescribed. Ask the following questions and write down the answers before leaving your healthcare provider’s office.
- What is the name of the medication and its active ingredient?
- For what condition or problem am I taking this medication and how does it work?
- Does it contain anything to which I am allergic? How long will it take to work?
- How should I store the medication? Does it need to be refrigerated?
- Are there any side effects? How will I know if a side effect is serious?
- Can the pharmacist substitute a less expensive, generic form of the medicine?
Find Out How to Take the Medication
Ask your doctor, pharmacist, or nurse about the right way to take any medicine before you start using it. Ask questions when you don’t know the meaning of a word or when instructions aren’t clear. Here are some specific questions to ask.
- Should I take it whenever I need it or on a specific schedule?
- Should I take it at a certain time of day?
- How much should I take each time?
- Do I need to take it with food?
- Should I lie down or remain upright after taking the medicine?
- May I drink alcohol while on this medication?
- How long will I have to take it?
Ask What to Expect
- How will I feel once I start taking this medicine?
- How will I know if this medicine is working?
- If I forget to take it, what should I do?
- What side effects might I expect? Should I report them?
- Can this medicine interact with other prescription and over-the-counter medicines — including herbal and dietary supplements — that I am taking now?
Tips for Taking Medicines Properly
Taking different medicines is not always easy to do properly. It may be hard to remember what each medicine is for, and how and when you should take each one. Here are some helpful tips for taking medicines.
- Check the label on your medicinebefore taking it to make sure that it is for the correct person — you.
- Read and save any written informationthat comes with the medicine.
- Take the medicine according tothe schedule on the label.
- Don’t take more or lessthan the prescribed amount of any medicine.
- If swallowing tablets is difficult,ask your health care provider or pharmacist whether there is a liquid form of the medicine or whether you could crush your tablets. However, do NOT break, crush, or chew tablets without asking a health professional first.
- Get into the habit of checking the expiration dateson your medicine bottles and throw away medicine that has expired.
- Try to set and follow a routine for taking your medicines.
Last Reviewed 09/07/2018