Drug Guide: Osteoporosis Medications

What do osteoporosis treatments do?

Osteoporosis medications (bisphosphonates included) can increase bone density and reduce the risk of fractures over time. Most osteoporosis drugs do this only by slowing bone loss: Bisphosphonates – alendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel) and zoledronic acid (Reclast); the hormone calcitonin; the estrogens; and the selective estrogen receptor modulator raloxifene (Evista). Only one osteoporosis drug – teriparatide (Forteo) – also promotes bone growth.

How is osteoporosis connected to arthritis?

Osteoporosis is not a form of arthritis. Rather, it is a disease in which bones become brittle and weak, and eventually may break. Fractures, such as in the hips, often have long-lasting effects, including less mobility, decreased quality of life and increased depression. Like arthritis, osteoporosis can lead to disability. If bones are weak, the joints they form just don’t work well. In addition, the underlying processes involved in arthritis may contribute to osteoporosis.

Researchers have discovered that the chemicals involved in the inflammatory process, called cytokines, inhibit bone-building. And, in some cases, medications – especially corticosteroids – used to treat joint inflammation induce osteoporosis. Age also connects people with osteoporosis and OA, because both conditions tend to occur later in life.

When does a doctor prescribe osteoporosis medications?

Doctors look at several pieces of information before prescribing a bone-preserving or bone-building medication. A key piece of information is a patient’s bone mineral density. Bone density is determined by a quick and painless dual-energy X-ray absorptiometry (DEXA) scan of the hips, spine and wrists – the bones most likely to break due to osteoporosis. People should have a DEXA scan at age 65 and at a younger age if they take corticosteroids (such as prednisone) or have rheumatoid arthritis.

In people who do not have their bone mineral density tested, bones can weaken “silently,” and a fracture may be the first indication of osteoporosis that requires treatment. For those who have a DEXA scan, results are given as a Tscore, which compares the strength of a person’s bones with the peak bone mass of young adults. If bone density is normal, the Tscore will be at or above -1. A T score ranging from -1.1 to -2.4 indicates osteopenia, a preosteoporosis condition. Osteoporosis is diagnosed if the T score is -2.5 or lower.

The National Osteoporosis Foundation recommends starting treatment for people who’s T score is -2.0 or lower, or for those who have additional risk factors (such as taking a corticosteroid) and a T score lower than -1.5. For patients on bone medications, or for those who remain at risk for osteoporosis, bone density tests may need to be repeated every one to two years. When deciding whether it’s time to prescribe an osteoporosis medication, a doctor also considers a patient’s family history of osteoporosis: lifestyle (calcium intake, exercise, smoking, alcohol use); and other factors, such as age, gender, height and weight.

How fast can osteoporosis progress without medication?

Disease progression is determined by genetics, lifestyle and environmental influences. Adequate or inadequate amounts of calcium, vitamin D and weight-bearing exercise can influence the rate of bone deterioration. Without medication, however, bones that are already weak can continue to lose density at a rate of 1 percent to 5 percent per year.

Do these medications work for men, too?

Men are fortunate to have options for treating bone loss now, as they certainly are not immune from developing osteoporosis. Just more than a decade ago, however, estrogens were the only treatment available, so men, children and women who didn’t want to risk estrogen’s side effects had no medical treatment options.

Now, all of the osteoporosis medications listed in the Drug Guide can be taken by men, except for the estrogens. In fact, three of the treatments – alendronate (Fosamax), risedronate (Actonel) and teriparatide injection (Forteo) – have been studied specifically in men and are FDA-approved for use in men at high risk of fracture due to osteoporosis.

How often must these drugs be taken?

Clinical studies throughout the past few years have shown that medication developed for daily use also can be effective if taken less frequently. Although daily doses are still available for most of the treatments, once-weekly, once-monthly and once-quarterly doses are also now available for some. Late last year, the treatment options for osteoporosis increased with the FDA’s approval of a once-yearly intravenous infusion treatment called zoledronic acid (Reclast). A new osteoporosis medication called denosumab is on the horizon, too, and is taken by injection just twice per year.

Do these medications cure osteoporosis?

There is no outright cure for osteoporosis, but with proper treatment and lifestyle changes, fracture risk can be reduced greatly. Potentially, there may be some restoration in the quantity and quality of bone tissue.  In some mild cases, after two to five years of treatment with medication – in addition to adhering to a healthy diet that provides adequate calcium, supplementing calcium and vitamin D if diet isn’t enough, and getting regular weight-bearing exercise – bone density may improve enough to attenuate, if not partially reverse, osteoporosis. Regular DEXA scans will determine if restarting medication is warranted. For severe osteoporosis, treatment likely will be life long.