Let's Talk About Osteoporosis Medication
You have options for treating brittle bones. Learn about the meds your doctor might prescribe and other must-knows for this journey.by Krista Bennett DeMaio Health Writer
Whether you have risk factors for developing osteoporosis or you’ve been diagnosed, you may wonder what the best avenues are for strengthening your bones. While there’s no cure for this bone-thinning condition, with the right meds, you can see improvement and slash your risk of fractures.
Our Pro Panel
We tapped top osteoporosis experts to bring you the most up-to-date information possible.
Saika Sharmeen, M.D.
Rheumatologist and Assistant Professor
Renaissance School of Medicine, Stony Brook University
Stony Brook, NY
Lara Than, M.D.
Department of Internal Medicine and Geriatrics
Kendall Moseley, M.D.
Johns Hopkins Metabolic Bone & Osteoporosis Center
No one drug stands out as the safest; all medications have side effects. You’ll have to weigh the pros and cons of each with your physician to find the right fit for you. Typically, bisphosphonates are well tolerated and have been shown to be safe to take for up to 10 years, which is why they’re the first line of treatment for osteoporosis.
There’s no cure for osteoporosis, but you can strengthen bones and reduce the risk of fracture by taking medications and making lifestyle changes. These include: boosting your calcium and vitamin D intake, doing weight-bearing exercises at least three days a week, drinking less alcohol (no more than one to two drinks a day), and if you’re a smoker, quitting.
No, osteoporosis drugs are not a lifelong commitment. You can take bisphosphonates for up to 10 years, but the latest osteoporosis guidelines suggest reassessing a patient’s bone density between three and five years, and, if possible, taking a break from the drugs. Bisphosphonates linger in your bones after you stop taking them, so you have some built-in protection. RANKL agents such as Prolia can be used up to 10 years, while anabolic agents can only be given for up to two years.
The risk of suffering a fracture is far greater than incurring some of the most serious side effects of medication. One in two women over age 50 will fracture a bone and fractures can be extremely painful and debilitating. Need more convincing? Consider this stat from a New York Times article: For every 100,000 women taking bisphosphonates, fewer than three will have osteonecrosis of the jaw, and only one will suffer an atypical femoral fracture. But 2,000 will have avoided an osteoporotic fracture.
What Is Osteoporosis? Let’s Review
Osteoporosis means porous bones. In short: It’s a condition that occurs when you lose more bone mass than your body can make. Think of your bones as a bank account: You spend the first couple of decades of your life socking away bone (money) for retirement. When you reach age 30 or so, you’ll hit your peak bone mass—the highest bone mass you’ll have in your lifetime. When you’re a kid, a calcium-rich diet, exercise, and general good health yield healthy bone development.
If you skimped on any of the above (say, due to a childhood illness), your peak bone mass might be on the low side. Once you reach that retirement age (over 50), you’ll need to make some withdrawals; this is when you start losing bone mass naturally and bone formation slows.
If you didn’t have a great peak bone mass to start with, you could get into trouble, leaving bones thin, brittle, and vulnerable to breaks. Certain risk factors—such as being a postmenopausal woman, having been on steroid medications such as prednisone, having an overactive thyroid condition, having undergone bariatric surgery or having a family history of osteoporosis —can also mean you’ll lose bone at a faster-than-normal rate.
What Is the Goal of Osteoporosis Treatment?
The end goal of all osteoporosis treatments is to stabilize your bone density—meaning, prevent you from losing additional bone—rather than achieve a complete cure. These meds are designed to slow your bone loss, and in some cases, help make new bones, so yours are less vulnerable to fracture (breaking).
That’s important because fractures aren’t just painful — they can be debilitating, leading to loss of mobility and independence, financial strain, and even death. The mortality rate a year after a hip fracture is about 22 percent. Yet, osteoporosis causes a staggering number of bone breaks a year: 1.5 million to be exact, according to research in the Journal of the American Medical Association.
Are Osteoporosis Drugs Given Preventatively?
To answer that, let’s start with what actually constitutes osteoporosis. The condition is often diagnosed when you have a bone density scan, a test that measures your bone mineral density (BMD).
The most common BMD test is a dual-energy X-ray absorptiometry or bone densitometry referred to as a DXA or DEXA scan. It checks the mineral levels in your bones, comparing your level to that of a 30-year-old of the same gender. The idea is to see how far your bone density has deviated since then. Here’s how to read your results, known as a T-score:
1.0 and above is considered normal
-1.0 to -2.4 is considered low bone density or osteopenia (meaning bone mass isn’t great, but it’s not yet osteoporosis)
-2.5 and above is considered osteoporosis
If you’ve suffered a fracture, your doctor will likely do a bone density scan to see if osteoporosis is at play. The scan is also routinely given to women starting at age 65 (at risk women can start at 60) and to men starting at 70 years old.
Your doctor will also determine how likely you are to fracture a major bone within the next 10 years via a Fracture Risk Assessment Tool (FRAX). If you have osteopenia and a low risk of fracture, you probably won’t be treated with an osteoporosis drug. Instead, the recommendation is to make lifestyle changes to improve, or at least stabilize, your bone density. What kinds of tweaks are we talking about? These may include:
Dietary changes (more calcium, vitamin D)
Weight-bearing exercises (walking, dancing, resistance training, etc.)
However, if you’re diagnosed with osteopenia and have a high risk of fracture, your physician may start you on osteoporosis meds to slow down your bone loss before it becomes osteoporosis. Medications aren’t always a given though. A person who is diagnosed relatively young with no history of fractures and is otherwise healthy may not need meds just yet.
What Medications Are Prescribed For Osteoporosis?
A few drug classes for osteoporosis that work in different ways to prevent fracture and a treatment plan may include one of the following types of drugs:
This family of meds give your natural bone production a chance to play catch-up by slowing or stopping resorption, when bones break down and release minerals such as calcium into your blood. They home in on and inhibit osteoclasts, the cells that do the breaking down. Antiresorptive drugs include:
You’ve probably heard of Fosamax or Boniva (or the Boniva generic ibandronate). They’re part of this drug class — the most commonly prescribed for osteoporosis. Bisphosphonates work by slowing down those osteoclasts, giving your osteoblasts (the bone-building cells) a chance to get ahead. Examples include:
Boniva (ibandronate), an oral tablet approved for women that’s taken monthly or via IV every three months.
Fosamax/Fosmax D Plus (alendronate), an oral tablet approved for women and men that’s taken daily or weekly.
Binosto (alendronate), a weekly effervescent tablet approved for women and men that dissolves in a liquid.
Actonel (risedronate), an oral tablet approved for women and men that’s taken daily, weekly, twice monthly, or monthly.
Atelvia (risedronate), an oral tablet approved for women that’s taken weekly.
Reclast (zoledronic acid), an IV infusion approved for women and men administered once a year.
Most drugs come with some risk of side effects, and bisphosphonates are no exception. The most common side effects of bisphosphonates are:
bone and joint pain
There is a side effect from Fosamax called osteonecrosis of the jaw (loss of blood supply to this bone). It’s a risk with all bisphosphonates, but it’s rare and usually seen in people receiving high doses of the meds during cancer treatments. Another less common side effect is atypical femoral fracture; (yes, an osteoporosis med can actually cause a bone break). Long-term use is linked to breaks in the upper thigh area. Zoledronic acid side effects can also include flu-like symptoms, but they’re temporary.
To reduce the risk of the more serious side effects, current osteoporosis treatment guidelines for bisphosphonates call for reassessing a patient’s fracture risk after three to five years. If your risk of fracture is low-to-moderate after treatment, you may be able to take a break from the drugs; those who are still high risk can remain on bisphosphonates for up to 10 years.
RANK Ligand (RANKL) Inhibitors
These injections work by neutralizing RANKL, a protein that’s necessary for osteoclasts to do their job breaking down bone. They’re given via injection every six months, depending on the brand, for up to 10 years. Example include:
Prolia, an injection approved for men and women, given every six months. Side effects include: constipation, muscle and back pain, weakness, rash, swelling, bloody, cloudy or painful urination.
Xgeva, an injection approved for men and women, given every four weeks. Side effects include: diarrhea, nausea, fatigue, joint and muscle pain.
RANKL injections can also lead to atypical fractures, and that risk is even greater if you suddenly stop treatment. A study in the journal Osteoporosis International found a five percent increase in multiple vertebral fractures after halting the osteoporosis treatment injection.
Hormone Replacement Therapy (HRT)
HRT cuts down on fragility fractures by 20 to 35 percent, studies have shown, but because of its potential health risks (pulmonary embolism, cardiovascular issues, and breast cancer are just a few), it’s considered a last resort treatment for osteoporosis alone and is reserved for women who are experiencing both menopause symptoms and osteoporosis. Side effects can include:
Swelling of the legs and feet
HRT is approved for women in the form of daily oral tablets and transdermal patches that are applied daily or weekly.
Selective Estrogen Receptor Modulators (SERMs)
SERMs aren’t hormones, so they don’t carry the same risks as traditional HRT, but this class of drugs does act similar to estrogen in the body by reducing menopause systems and fortifying your bones and preventing fracture, particularly in the spine.
It’s a good option for women who are dealing with both menopause symptoms and osteoporosis, but have a high risk of breast cancer that eliminates HRT as an option. SERMs are taken as a daily tablet. One example is Evista (raloxifene), a daily oral tablet approved for women. Evita’s most common side effects are:
Tissue-Specific Estrogen Complex (TSEC)
This type of drug, like Duavee (conjugated estrogens/bazedoxifene) combines estrogen with a SERM to help with severe menopause symptoms such as hot flashes and boost bone mineral density. Research has shown it can increase both spine and hip density after 12 months. It’s a daily tablet that’s taken orally. Side effects can include:
Because TSEC contains estrogen, it carries some of the risks of HRT.
These are your bone builders. This osteoporosis drug class is designed to stimulate osteoblasts, the cells that beef up bone formation. They’re typically reserved for more severe cases of osteoporosis where the risk of fracture is very high. Anabolics include:
Evenity (romosozumab-aqqg) given once a month for a year
Forteo (teriparatide) injection is given daily and is limited to two years of use
Tymlos (abaloparatide) is a daily injection also with a two-year cap
The most common side effects of these osteoporosis treatment injections are:
The newest bone maker on the block, romosozumab-aqq, is an anti-sclerosin monoclonal antibody approved for postmenopausal women with high risk of fracture. It comes with a risk of cardiovascular issues, so if you’ve had a heart attack or a stroke within the past year, this is not an ideal drug. Teriparatide and abaloparatide are synthetic versions of parathyroid hormone, which regulates calcium, essential for strong bones.
While worries about side effects may give you pause about filling your prescription for osteoporosis meds, it’s important to remember this: The benefits of preventing a fracture (and all that comes with it) win out over the risks of taking these meds, according to guidelines from the Endocrine Society published in The Journal of Endocrinology & Metabolism.
Can You Combine Meds?
It’s not widely done, but there’s evidence that pairing an antiresorptive with an anabolic agent may yield better results than giving one drug alone. One study in the Journal of Bone and Mineral Research showed combining the bisphosphonate zoledronic acid with the anabolic teriparatide boosted bone mineral density in the spine and hip more than either drug alone.
In an analysis of seven studies, research in the BMJ Open found that a combo of the two drug classes greatly improved bone mineral density of the hip and spine more quickly than an anabolic agent alone. Some doctors will also give an anabolic first (in severe cases) and prescribe a bisphosphonate to maintain your newly formed bone mass.
What Other Drugs May Help Bones?
While bisphosphonates and anabolic agents are the most common osteoporosis medications, some drugs that are used to treat other conditions that can also have a positive effect on bone density.
You’ve probably heard steroids are bad for bones. It’s true; long-term use of corticosteroids (synthetic drugs that are similar to cortisol, a hormone your body produces) deteriorates bone mineral density, causing osteoporosis. But low doses of anabolic steroids (synthetic versions of the male hormone androgen) may have the opposite effect, stimulating bone growth and reducing osteoporosis pain from fractures, according to research in Clinical Calcium. However, there’s limited data to know the long-term side effects of anabolic steroids.
This used to be a malaria medication. How can that possibly help your bones? Hydroxychloroquine is antirheumatic, meaning it’s used to treat rheumatoid arthritis (RA), lupus, Sjögen syndrome, etc. Researchers discovered those treated with Plaquenil had higher bone mineral density than those who weren’t. It’s not FDA approved for osteoporosis and comes with a rare, but serious risk of eye damage in high doses. More common side effects include:
This is another type of bisphosphonate given via IV infusion that slows down bone loss, but it’s primarily used to treat bone damage from Paget’s Disease (a chronic disease that causes deterioration of bone tissue) and certain types of cancer, as well as hypercalcemia (high levels of calcium in blood caused by calcium). It’s an option for osteoporosis patients, but zoledronic acid has proved better for fracture prevention.
What About Natural Supplements for Osteoporosis?
Right now, there are no natural supplements that experts recommend in lieu of FDA-approved osteoporosis drugs. If you’ve been searching the internet for that, you’ve probably come across info on strontium, a trace element, for osteoporosis.
There is some scientific basis on this one. A study found that postmenopausal women who took two grams of strontium ranelate every day for three years suffered 37 percent fewer spinal fractures compared to women taking a daily placebo pill.
There’s also a strontium ranelate-based drug (Protelos) approved in Europe, but not here in the US. (It’s associated with some serious side effects such as pulmonary embolism and heart attacks.) So, should you take an over-the-counter version of the mineral, such as strontium citrate or strontium chloride, to strengthen your bones? Not so fast. These are not the same as strontium ranelate, and there’s no evidence they work.
What about OTC estrogen pills? Phytoestrogens, plant-based versions of the hormone such as soy and flaxseed, have some limited data behind them to show that they may help slow bone loss. But physicians say not enough to replace your prescribed medication. Phytoestrogens in your diet may be better at preventing low bone density than treating osteoporosis.
- Hip Fracture and Mortality Rate: World Journal of Orthopedics. (2019). “Changing Trends in the Mortality Rate at 1-Year Post Hip Fracture - A Systematic Review.” ncbi.nlm.nih.gov/pmc/articles/PMC6428998/
- Osteoporosis Treatment Guidelines: The Journal of Clinical Endocrinology & Metabolism. (2019). “Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Clinical Practice Guideline.” academic.oup.com/jcem/article/104/5/1595/5418884
- Fracture Stats: The American Journal of Medicine. (2006). “Osteoporosis-Related Fractures: An Overview.” amjmed.com/article/S0002-9343(05)01197-6/fulltext
- Hormone Replacement Therapy for Osteoporosis: International Osteoporosis Foundation. (n.d.). Hormone Replacement Therapy (HRT). iofbonehealth.org/hormone-replacement-therapy-hrt
- Combining Drug Therapies: Journal of Bone and Mineral Research. (2011). “Effects of Intravenous Zoledronic Acid Plus Subcutaneous Teriparatide in Postmenopausal Osteoporosis.” ncbi.nlm.nih.gov/pubmed/20814967
- Anabolic Agents and Bisphosphonates: BMJ Open. (2016). “Combination Therapy of Anabolic Agents and Bisphosphonates on Bone Mineral Density in Patients with Osteoporosis: A Meta-Analysis of Randomized Controlled Studies.” bmjopen.bmj.com/content/8/3/e015187
- Anabolic Steroids and Osteoporosis: Clinical Calcium. (2008). “Effects of Anabolic Steroids on Osteoporosis.” ncbi.nlm.nih.gov/pubmed/18830042
- Plaquenil and Osteoporosis: Journal of Cellular Physiology. (2018). “Hydroxychloroquine Affects Bone Resorption Both in Vitro and in Vivo.” ncbi.nlm.nih.gov/pubmed/28556961
- Strontium and Osteoporosis: Harvard Health Publishing. (2007). “By the Way, Doctor: Can Strontium Help Treat Osteoporosis?” health.harvard.edu/newsletter_article/By_the_way_doctor_Can_strontium_help_treat_osteoporosis
- Osteoporosis Drug Fears: The New York Times. (2016). “Fearing Drugs Rare Side Effects, Millions Take Their Chances with Osteoporosis.” nytimes.com/2016/06/02/health/osteoporosis-drugs-bones.html