Osteoporosis treatment: Medications can help

If you're undergoing osteoporosis treatment, you're taking a step in the right direction for your bone health. But perhaps you have questions about your therapy. Is the medicine you're taking the best one for you? How long will you have to take it? Why does your healthcare professional recommend a weekly pill when your friend takes a pill only once a month?

Which osteoporosis medicines are usually tried first?

Bisphosphonates are often the first choice for osteoporosis treatment. These include:

• Alendronate (Fosamax), a weekly pill.
• Risedronate (Actonel, Atelvia), a weekly or monthly pill.
• Ibandronate, a monthly pill or quarterly intravenous (IV) infusion.
• Zoledronic acid (Reclast), an annual IV infusion.

Another common osteoporosis medicine is denosumab (Prolia). Unrelated to bisphosphonates, denosumab might be used in people who can't take a bisphosphonate or did not tolerate one, such as some people with reduced kidney function.

Denosumab is delivered by injections, just under the skin, every six months. If you take denosumab, you might have to do so until your healthcare professional transitions you to another medicine. Unlike bisphosphonates, denosumab is not taken for a certain time and then simply stopped. It is followed by other medicine. Research shows that there could be a high risk of spinal fractures after stopping denosumab, so it's important that you take it consistently.

What are common side effects of bisphosphonate pills?

The main side effects of bisphosphonate pills are stomach upset and heartburn. Don't lie down or bend over for 30 to 60 minutes to avoid the medicine washing back up into the esophagus. Most people who follow these tips don't have these side effects.

Bisphosphonate pills aren't absorbed well by the stomach. It is important to take the medicine with a tall glass of plain water on an empty stomach, before first food or other medications or pills in the morning. Don't put anything else into your stomach for 30 to 60 minutes. After waiting, you can eat, drink other liquids and take other medicines.

Do intravenous bisphosphonates have advantages over the pill form?

Intravenous forms of bisphosphonates, such as ibandronate and zoledronic acid, don't cause stomach upset. And it may be easier for some people to schedule a quarterly or yearly infusion than to remember to take a weekly or monthly pill.

Intravenous bisphosphonates may cause mild flu-like symptoms in some people, but usually only after the first infusion. You can lessen the effect by taking acetaminophen (Tylenol, others) before and after the infusion.

Can osteoporosis medicines hurt your bones?

A very rare complication of bisphosphonates and denosumab is a break or crack in the middle of the thighbone. This injury, known as atypical femoral fracture, can cause pain in the thigh or groin that begins subtly and may gradually worsen.

Bisphosphonates and denosumab also can cause osteonecrosis of the jaw. This is a rare condition in which a section of jawbone is slow to heal or fails to heal, often after a tooth is pulled or other invasive dental work. This happens more commonly in people with cancer that involves the bone as they may take much larger doses of a bisphosphonate than those typically used for osteoporosis.

Should I take a drug holiday from bisphosphonates?

The risk of developing atypical femoral fracture or osteonecrosis of the jaw tends to increase the longer you take bisphosphonates. So your healthcare professional might suggest that you temporarily stop taking this type of drug. This practice is known as a drug holiday.

Even if you stop taking the medicine, its positive effects can persist. That's because after taking a bisphosphonate for several years, the medicine remains in your bone.

Because of this lingering effect, most experts believe that it's reasonable for people who are doing well during treatment — those who have not broken any bones and are maintaining bone density — to consider taking a holiday from their bisphosphonate after taking it for five years.

Are hormones used to treat osteoporosis?

Estrogen, sometimes paired with progestin, was once commonly used to treat osteoporosis. This treatment can increase the risk of blood clots, endometrial cancer, breast cancer and possibly heart disease. It's now usually reserved for women at high risk of fracture who can't take other osteoporosis drugs.

Women who are considering hormone replacement therapy to reduce menopausal symptoms, such as hot flashes, may factor in increased bone health when weighing the benefits and risks of estrogen treatment. Current recommendations say to use the lowest dose of hormones for the shortest period of time.

Raloxifene (Evista) mimics estrogen's beneficial effects on bone density in postmenopausal women, without some of the risks associated with estrogen. Taking this drug can reduce the risk of some types of breast cancer. Hot flashes are a common side effect. Raloxifene also may increase your risk of blood clots.

How do osteoporosis medicines work?

Throughout your life, healthy bones continuously break down and rebuild. As you age — especially after menopause — bones break down more quickly. Because bone rebuilding cannot keep pace, bones deteriorate and become weaker.

Most osteoporosis medicines work by reducing the rate at which your bones break down. Some work by speeding up the bone-building process. Either mechanism strengthens bone and reduces your risk of fractures.

Which medicines help speed up the bone-building process?

Bone-building medicines include:

• Teriparatide (Forteo).
• Abaloparatide (Tymlos).
• Romosozumab (Evenity).

These types of medicine are typically reserved for people who have very low bone density, who have had fractures or whose osteoporosis is caused by steroids. They also may be used when other medicines are not tolerated, or bone density worsens despite other medications. They are not usually used in combination or along with the other medicines.

Teriparatide and abaloparatide require daily injections. Studies in laboratory rats found an increase in the risk of bone cancer, so these medicines are not used in people at high risk of bone cancer. But these medicines have been in use for more than 10 years and so far an increase in bone cancer has not been found in people who have taken these medicines.

Romosozumab is given as a monthly injection at your healthcare professional's office. It is a new drug and less is known about long-term side effects. It is not given to people who have recently had a stroke or heart attack. Treatment stops after 12 monthly doses.

These bone-building medicines can be taken for only one or two years and the benefits begin disappearing quickly after you stop. To protect the bone that's been built up, you'll need to start taking a bone-stabilizing medicine such as a bisphosphonate.

Can medicine alone successfully treat osteoporosis?

Don't rely entirely on medicines as the only treatment for your osteoporosis. These practices also are important:

• Exercise. Weight-bearing physical activity and exercises that improve balance and posture can strengthen bones and reduce the chance of a fracture. The more active and fit you are as you age, the less likely you are to fall and break a bone.
• Good nutrition. Eat a healthy diet and make sure you're getting enough calcium and vitamin D.
• Quit smoking. Smoking cigarettes speeds up bone loss.
• Limit alcohol. If you choose to drink alcohol, do so in moderation. For healthy women, that means up to one drink a day. For healthy men, it would be up to two drinks a day.