What medications are available to treat osteoporosis?
There are a number of different medications used to treat osteoporosis. Some work by decreasing how fast bone is broken down, others increase the rate at which bone is built back up. Some can only be used in postmenopausal women.
Osteoporosis treatment should be considered in postmenopausal women and men aged 50 and older who fracture their hip bone or a vertebrae in their spine; or who present with a bone density T-score of less than -2.5 (taken at the femoral neck of the hip, or total hip, or lumbar spine), or with a low bone mass (T-score of -1.0 to -2.5) with other risk factors for a fracture.
Bisphosphonates (such as Actonel, Atelvia, Boniva, Binosto, Fosamax, Reclast, or Zometa) are the most commonly prescribed treatment. However, menopausal hormonal therapy, raloxifene, denosumab or teriparatide (brands include Forteo or Bonsity) may be a better option for some people. All require a prescription from a doctor, and apart from teriparatide, all decrease the rate at which bone is broken down. Teriparatide increases the rate at which bone is built up and also increases the absorption of calcium.
Your insurance plan will determine how much your insurance company pays for your osteoporosis medication, and you may have to pay a certain amount or a co-pay. Check your insurance companies website for a list of osteoporosis medications that they are approved to pay for. Some people may also qualify for the Medicare Prescription Drug benefit.
Bisphosphonates: Most Commonly Prescribed For Osteoporosis
Bisphosphonates block the action of osteoclasts - responsible for breaking down bone tissue - thereby slowing bone loss.
Bisphosphonates available in the U.S. include:
- Alendronate (Fosamax, Binosto): may be taken orally daily or a weekly tablet is also available
- Ibandronate (Boniva): can be taken orally monthly or given by intravenous injection every three months
- Risedronate (Actonel, Atelvia): can be taken orally daily, weekly, bimonthly, or monthly
- Zoledronic acid (Reclast, Zometa): given by intravenous infusion over at least 15 minutes once a year when used for treatment or once every two years when used for prevention.
Hormone Replacement Therapy for Osteoporosis
Twenty-to-thirty years ago, menopausal hormone therapy (MHT) (previously called hormone replacement therapy [HRT]) was considered the gold standard for preventing not only osteoporosis but treating menopausal symptoms as well. That all changed after publication of the results of the Women's Initiative Trial in 2002 which showed the risks associated with MHT use (an increased risk of breast cancer, blood clots, heart attacks, and stroke) outweighed the benefits (decreased rates of hip and vertebral fractures and colon cancer).
MHT may consist of either estrogen therapy alone or an estrogen-progestin combination. While not recommended as first-line osteoporosis therapy, estrogen may still be used to prevent osteoporosis in young women with premature menopause or primary ovarian failure. In women who are postmenopausal, it is usually reserved for those with persistent, intolerable menopausal symptoms or in those who do not tolerate other osteoporosis treatments. Examples of hormonal treatments include Premarin, estradiol, and Femhrt.
Raloxifene: Estrogen-Like Effects Without Cancer Risk
Raloxifene (Evista) is an estrogen agonist/antagonist (formerly called a selective estrogen receptor modulator [SERM]) that decreases bone resorption and turnover in postmenopausal women.
Although raloxifene is not a hormone, it mimics the action of estrogen on bones while at the same time blocking the effect of estrogen on other tissues. Therefore, long-term use of raloxifene does not carry the same risk to breast and womb tissue associated with estrogen-based hormone therapies. However, raloxifene can increase the risk of deep vein thrombosis and stroke and may increase the incidence of hot flushes and leg cramps. Raloxifene may also be used to treat osteoporosis in postmenopausal women with invasive breast cancer. Evidence suggests it may not be as effective as bisphosphonates or estrogen at preventing bone loss.
Duavee: Effective For Menopausal Symptoms And Bone Loss
Duavee is the brand name for a once-daily combined conjugated estrogens/bazedoxifene tablet approved for the treatment of vasomotor symptoms (such as night sweats and hot flushes) associated with menopause and for the prevention of osteoporosis.
The bazedoxifene component of the drug acts as an estrogen antagonist and prevents some of the estrogen side effects (such as excessive growth of the uterine lining) that could occur if estrogen was used by itself. Duavee increases both lumbar spine and hip bone mineral density but carries similar risks to other hormonal products so should only be considered if alternative non-estrogen products are not suitable.
Denosumab: Targeting The Cells That Break Down Bone
Denosumab (Prolia) is an antibody that targets RANKL - a receptor directly involved in the formation of osteoclasts, the cells that break down bone.
Denosumab improves bone mineral density and decreases fracture risk and is approved in postmenopausal women and men with osteoporosis at high risk of fracture. It may also be used to treat bone loss in men with prostate cancer or women with breast cancer undergoing hormone ablation therapy, or for the treatment of glucocorticoid-induced osteoporosis in those at high risk of fracture.
Denosumab is usually reserved for people intolerant of or unresponsive to oral or intravenous bisphosphonates.
Teriparatide: Unique Action Comes At A Cost
Teriparatide (Forteo), is a synthetic form of parathyroid hormone - a hormone produced naturally by the body which helps maintain blood levels of calcium within a very tight range; which in turn controls calcium levels within bone - determining how strong and dense the bones are.
As an osteoporosis medication, teriparatide is unique in that it stimulates bone formation. It may be used by postmenopausal women or men and is given as a daily injection. Evidence suggests it has more of an effect on building bone density and reducing fracture risk in the spine compared to other areas. Forteo is expensive, so is usually reserved for people with severe osteoporosis.
Bonsity (teriparatide) is a parathyroid hormone analog (PTH 1-34) that was approved in October 2019 and represents a cost-effective, therapeutically equivalent option to Forteo. It may be used to treat the following people at high risk of fracture:
Evenity: The Only Bone Builder with a Dual Effect
In April, 2019, the FDA approved Evenity (romosozumab-aqqg) for postmenopausal women at high-risk of fracture. It is currently the only bone builder to increase both bone formation and reduce bone loss.
Evenity is a humanized monoclonal antibody that works by inhibiting the activity of sclerostin, which is a small protein found in osteocytes. It is given by injection by a healthcare provider once a month for a treatment period of 12 months. After the 12-month course, therapy should continue with an anti-resorptive agent.
The main side effects associated with Evenity are joint pain (arthralgia) and headache. Evenity can also increase a woman's risk of having a heart attack and stroke, and for this reason it carries a boxed warning, and should not be given to women with other cardiovascular risk factors.
Tymlos: Another Option For Postmenopausal Women
Tymlos (abaloparatide), approved in April 2017, is a man-made version of a protein related to human parathyroid hormone. It may be considered in postmenopausal women who have tried and not responded to, or been intolerant of, other medications for osteoporosis. Tymlos significantly reduces the risk of vertebral and nonvertebral fractures.
Some animal studies have found that Tymlos is associated with an increase in the risk of osteosarcoma (a type of cancerous bone tumor). It is not known if this increased risk translates to humans; however, authorities have warned that Tymlos should not be given to women already at increased risk of osteosarcoma, including those with Paget's disease of the bone, pre-existing bone malignancies, prior radiation therapy, or hereditary disorders that increase their risk of osteosarcoma.
Tymlos is given by self-injection just under the skin and is available as single-use prefilled pens.
Calcitonin May Not Reduce Fracture Risk
Calcitonin is a hormone that works together with naturally occurring parathyroid hormone to help regulate calcium concentrations on the body. It may be given by nasal spray or injection to women who are five years postmenopausal; however, the nasal spray is preferred because the injection tends to cause nausea and flushing.
Other treatments are usually preferred over calcitonin for the prevention of osteoporosis because it is not clear if calcitonin increases bone density in areas other than the spine or if it prevents fractures. Calcitonin is also used to relieve sudden, intense pain caused by vertebral fractures.
Can you prevent osteoporosis?
Osteoporosis is not considered a normal part of aging and osteoporosis prevention should begin in childhood. Build stronger bones at any age by:
- Eating enough calcium-rich foods. Experts recommend that your diet contains around 500mg to 1000mg of calcium from food sources every day. This equates to about two to four servings of dairy products; nondairy sources of calcium include almonds, broccoli, figs, tinned whole fish (salmon with bones, sardines), and tofu. Calcium supplements are not recommended, as they may increase the risk of heart disease
- Exposing your skin to a safe amount of sunlight so that your body can make enough Vitamin D. Vitamin D is vital for good bone health and people who spend a lot of time indoors or who have dark skin are at risk of vitamin D deficiency. If getting outside is not possible, vitamin D supplements may be considered
- Partaking in weight-bearing exercise because this builds bone strength by making you move against gravity while staying upright. Weight-bearing exercise can be classed as those exercises that are high-impact - such as dancing, running, tennis, and aerobics - and those that are low impact. Many gym machines such as treadmills, stair-step machines and elliptical trainers are low impact as is fast walking outside. Low-impact weight-bearing exercises are a safe alternative to high-impact exercise in those people who already have osteoporosis or who are at risk of breaking a bone.
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