Bisphosphonates: The Drugs We Love to Hate

by PJ Hamel Patient Expert

Should I go back on Boniva even though there have been reports of it harming the liver?Fosamax is not good for people with glaucoma. What medication is better?What are the side effects for men taking Actonel?

These questions are just a few of the many posted in the Q & A section of this site. And the majority of questions you'll read here are about drugs: not osteoporosis itself, nor its causes, nor questions about a cure. I also answer questions on HealthCentral's breast cancer site, and there the vast majority of questions center around fear: "Here are my symptoms; do I have breast cancer?" Very seldom does a woman want to know about the drugs so many of us survivors routinely take.

Yet for those of us with osteoporosis, it's all about the drugs. There are no clear symptoms to worry about; and there's no known cure. So what's left? Treatment. And that means drugs: in most cases, bisphosphonates, the long-time gold standard medication for osteoporosis prevention and treatment.

Millions of us take (or have tried to take) oral bisphosphonates. And millions of us do regular battle with them, too. This most common class of osteoporosis drugs includes Boniva, Fosamax, and Actonel. And most of us have a love-hate relationship with them: while they work to slow down osteoporosis, they also come with a host of potential problems and side effects.

Bisphosphonates, also called anti-resorptives, work by slowing the rate at which your bones "shed," or lose their density. Throughout your life, your bones break down, and then build back up; it's their natural cycle of growth. When you're young, your bones build up faster than they break down. It makes sense; they need to grow, to lengthen and thicken in pace with the rest of your body.

During middle age, your bones no longer need to become larger; they build up and break down at an even pace. But as you age, your bones start to break down more quickly than they can rebuild. If the balance tips too far towards breakdown, bingo: you've got osteoporosis.

And what do bisphosphonates do? They slow the pace of bone breakdown, putting it more in balance with bone buildup. Thus your bone density increases. How do they do this? By hindering the cells (osteoclasts) that break down your bones; and perhaps by stimulating the cells (osteoblasts) that build up your bones. So far, so good, right?

Well" yes and no. Bisphosphonates have been known to chemists since the 19th century, and were originally found in fertilizer and washing powder, among other uses. This should tell you something about their potency and the care with which they need to be administered.

Typically, someone taking an oral bisphosphonate is advised make that ordered to take it first thing in the morning, on an empty stomach, with 6 to 8 ounces of plain water. After that, the person may not eat anything for 30 minutes, and must also remain upright during that time.

OK, it doesn't sound complicated; but it also sounds like a pain in the neck. I don't know about you, but for me this conjures up visions of awakening 30 minutes early in order to carry out this very specific routine. And what happens if you make a mistake along the way? Hey, we're talking early morning and an empty stomach (bleary eyes, a fuzzy brain), a situation where most of us don't function very well. What if somehow that pill doesn't get to its intended destination? "Severe gastrointestinal problems," including heartburn, and irritation/inflammation of the esophagus: esophagitis. Additionally, you might experience nausea, ulcers, abdominal pain, headache, joint/muscle pain, constipation, diarrhea, difficulty swallowing, and increased gas.

Is it any wonder, given the regimented way these drugs must be taken and the severe consequences if they're not, that so many of us fall off the wagon?

Yet, if these are the best drugs currently available, how can we afford not to take them?

Next time, we'll examine these three drugs further: how they differ, which one is right for you, and how to minimize the possibility of those nasty side effects.

PJ Hamel
Meet Our Writer
PJ Hamel

PJ Hamel is senior digital content editor and food writer at King Arthur Flour, and a James Beard award-winning author. A 16-year breast cancer survivor, her passion is helping women through this devastating disease. She manages a large and active online survivor support network based at her local hospital and shares her wisdom and experience with the greater community via