When Michelle Easton, 56, was diagnosed with osteoporosis five years ago, her doctor prescribed Fosamax. Michelle was diligent about taking the pill every week - and remaining upright for the required time afterward without eating or drinking anything other than water - but over the next few years, her bone density decreased further. But Michelle, who lives in the Virginia suburbs of Washington D.C., faithfully continues her regimen and the bone loss has finally stabilized.
"It's a bit of a bother, but before I know it, the hour is gone," says Michelle, who takes the weekly medicine on a Saturday or Sunday so she will have time to shower and dress leisurely before eating breakfast at the allowed time. The inconvenience is worth it, she says, because her osteoporosis might be even worse without the medication.
The first 48 hours after being diagnosed with osteoporosis can be a stressful time, especially if your physician brings up prescribing medication. Many osteoporosis medicines, especially bisphosphonates - such as Fosamax (alendronate), Boniva (ibandronate) and Actonel (risedrontate) - are as well-known for their gastrointestinal side effects as for their bone-building potential."It's a very individual thing," says Dr. Linda F. Bach, who specializes in internal medicine and has a family practice in Miami Shores, Fla. "A lot of people, no matter how bad you tell them their osteoporosis is, don't want to take any medicines."
Bisphosphonates, which many doctors consider the first line of defense against osteoporosis, work by suppressing or inhibiting the body's natural process of bone breakdown, known as bone resorption. The medicine leads to the apoptosis, or cell death, of the body's osteoclasts, which normally dig out portions of older bone. This allows the balance to swing toward the osteoblasts, which build bone.
For many patients, a primary drawback of bisphosphonates is the requirement to take it first thing in the morning, remaining upright for at least 30 minutes afterwards, and not consuming anything but water. Potential side effects include nausea, heartburn, irritation of the esophagus and other gastrointestinal problems - especially for those who don't follow the instructions closely.
In addition, there has been some controversy over the association of these medicines with a condition known as osteonecrosis of the jaw, or dead bone tissue. Symptoms of this side effect can include toothache, loose teeth, jaw pain, recurrent infections in the soft tissue and failure of the jaw to heal normally after a procedure such as an extraction. However, most bisphosphonate users who develop osteonecrosis of the jaw are those patients who take the medication intravenously at levels required to combat cancer.For postmenopausal women unable to tolerate the side effects of bisphosphonates, many doctors prescribe Evista (raloxifene). This type of drug is called a Selective Estrogen Receptor Modulators or SERM because it has the same positive effects on the bone as estrogen while limiting its negative health effects on other parts of the body. However, the medicine is not recommended for anyone at risk of pulmonary embolism.
While hormone replacement therapy was once commonly used to help ward off osteoporosis, its use has been severely restricted in recent years because of a demonstrated increase in serious medical problems such as stroke and heart disease, and possibly even breast cancer. However, women younger than menopausal age who take hormone therapy because of a hysterectomy or other reason still experience these protective benefits for the bone.
For those whose osteoporosis is severe, some physicians turn to an anabolic medication - specifically, synthetic parathyroid hormone, or teriparatide. Sold under the brand name Forteo, it is taken as a daily injection. Unlike bisphosphonates, it stimulates the bone-building osteoblasts directly. However, some clinical studies have shown an increase in osteosarcoma, or bone cancer, in rats taking high levels of this drug. No such cases have been reported in humans. According to the manufacturer, the safety and efficacy of treatment with Forteo for longer than two years has not been evaluated and therefore is not recommended.
If you have a long history of taking corticosteroids, such as Prednisone, be sure to discuss it with your doctor. The ongoing use of these drugs, as may be needed to treat rheumatoid arthritis or chronic obstructive pulmonary disease (C.O.P.D., or emphysema), has been shown to reduce bone mass. "You're not going to reach peak bone mass," advised Dr. Carlos Lozada, associate professor of rheumatology and immunology at the University of Miami Miami Miller School of Medicine and director of its Rheumatology Fellowship Program, at a seminar he led in May at Cedars Medical Center in Miami, Fla. "The amount you're going to start going down from is lower." In fact, in some cases, doctors prescribe bisphosphonates or other osteoporosis medicines concurrently with the corticosteroids in order to mitigate the risk of a fracture.
A number of new osteoporosis medications, and new formulations of existing treatments, are also working their way through the pipeline from research to reality. For example, the bisphosphonate zoledronic acid - an intravenous medicine now used to treat other diseases - has shown in studies to be effective against osteoporosis. While some doctors are already prescribing it off-label for the condition, for many the cost will remain prohibitive until the drug gains FDA approval for use as an osteoporosis drug and is covered by insurance for that purpose.
Before beginning any medication for osteoporosis, it very important to inform your physician of any other medicines you might be taking, in case of possible side effects or drug interactions. You may also want to reconsider any medicines that could cause sleepiness or dizziness, such as antihistamines or sleep aids, which might increase the risk of a fall. In some cases your doctor may recommend stopping, reducing, or substituting those medications.
Never start or stop any medication without close consultation with your physician. And if you and your doctor establish a prescription regimen, do your best to stick with it. Sadly, studies have shown osteoporosis patients have among the worst compliance rates for medication among those with chronic conditions. Medication sitting in the cabinet has zero effectiveness, so take it as directed or check with your doctor right away if you need to stop because of side effects or some other reason.
As Dr. Bach points out, even bone density scans are not perfect indicators of the benefits your bones may be receiving from the medicine. Studies have demonstrated that many of these medicines help prevented fractures even more than would be predicted strictly by the effects on bone density, possibly as a result of the drugs' changes to the bone architecture.
Weighing the pros and cons of a prescription regimen to help combat osteoporosis is a personal decision only you can make in conjunction with your physician. Many people ultimately decide the potential benefits in preventing fractures outweigh the risks. Combined with other lifestyle changes to fight the onset of osteoporosis, medication prescribed by your doctor can be an option worth seriously considering.
Published On: July 30, 2007