Calcitonin Or Forteo: Bypassing The Bisphosphonates

Patient Expert

While bisphosphonates Fosamax, Boniva, et. al. are certainly the most common osteoporosis drugs, they're not the only ones you might be prescribed. Especially if you have digestive issues (if you're prone to heartburn, nausea, etc.), your doctor might recommend a drug that's gentler on the stomach. Here are a couple of possibilities:

This is a manufactured version of a naturally occurring hormone, and it comes in two brands: Fortical ®, and Miacalcin ®.

How will it help me?
Calcitonin works just like a bisphosphonate: by slowing the work of bone-destroying osteoclast cells, and (perhaps) encouraging osteoblast cells to increase the pace of bone buildup. It's effective for reducing spinal fractures, though it hasn't been shown effective in other parts of the body, including the hip.

Is it recommended for me?
Calcitonin is recommended for the treatment of osteoporosis (not osteopenia) in women with low or falling bone mass who are 5 or more years past menopause. It isn't recommended for men, nor for pre-menopausal (or even recently post-menopausal) women.

Calcitonin is especially recommended for women who can't handle the regimen of a bisphosphonate, for whatever reason: inability to stay upright for 30 minutes, need to eat first thing upon arising in the morning, or problems with heartburn or other digestive issues.

Although it's not FDA-approved for this use, there's anecdotal evidence that calcitonin actually helps ease the pain of any tiny osteoporotic fractures you might have.

When and how would I take calcitonin?
Either Fortical or Miacalcin is taken in a dosage of 200 IU once a day as a nasal spray, alternating nostrils day by day. It doesn't have to be taken at any particular time; and, since it's absorbed directly into your bloodstream and bypasses your stomach, can be taken with or without food.

And what are the common side effects?
The most common side effect is nasal irritation, which can include minor bleeding, redness, itching, tenderness, dryness, crusting, scabs, or congestion. You may also experience bone or joint pain. A less common side effect is light-headedness; or impairment of your thinking or reaction time. A systemic allergic reaction is a rare side effect; if your doctor suspects you may be allergic to calcitonin, (s)he will give you an allergy skin test prior to prescribing.

Parathyroid hormones

Currently, there's only one FDA-approved drug in this class, thus only one used for osteoporosis treatment in the U.S.: Forteo.

How will it help me?
Your body manufactures parathyroid hormones, which stimulate your osteoblasts to build bone. Forteo is the synthesized (manufactured) version of this hormone. In effect, it increases bone density by just the opposite method of a bisphosphonate: it stimulates bone buildup (osteoblasts), rather than slowing down bone breakdown (osteoclasts). Forteo also helps your body absorb calcium, which is key to bone buildup.

Is it recommended for me?
Forteo is recommended for the treatment of osteoporosis in both men and post-menopausal women at high risk for fracture. Compared to a bisphosphonate, it increases bone mineral density in the spine to a greater degree, and more quickly. It's especially recommended for anyone who's already suffered a fracture due to osteoporosis, or who's at high risk and unable to tolerate a bisphosphonate

When and how would I take Forteo?
Forteo is given as a daily injection under the skin of your thigh or stomach, for a limited period of 2 years. You can give yourself the injection at home via a delivery "pen," which has recently been improved and is much easier to use than earlier models.

And what are the common side effects?
You may have mild dizziness; pain or itching around the injection site; leg cramps; or nausea. Less commonly, you might experience joint pain; headache or neck pain; a runny nose, or other nasal issues; diarrhea, or constipation.

A serious side effect, one that should be reported to your doctor, is an allergic reaction: difficulty breathing, and swelling of the lips, face, tongue, or throat.

Forteo is associated with an increased risk of bone cancer in lab rats. Since the drug is still relatively new (it received FDA approval late in 2002), studies showing any possible link to bone cancer in humans are not yet complete. For this reason, your doctor may advise against Forteo if you've ever had radiation to the bones.