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Medications Prescribed for Osteoporosis

The goal of osteoporosis treatment is to prevent broken bones and fractures. This is done by stopping bone loss and by increasing bone density and strength. Early detection and treatment of osteoporosis can decrease the risk of future bone fracture. None of the available treatments for osteoporosis are complete cures. It is difficult to completely rebuild bone that has been weakened by osteoporosis. Therefore, prevention of osteoporosis is as important as treatment.

Osteoporosis treatment and prevention measures are:

  • Lifestyle changes including quitting cigarette smoking, curtailing alcohol intake, exercising regularly, and consuming a balanced diet with adequate calcium and vitamin D
  • Medications that stop bone loss and increase bone strength, such as alendronate (Fosamax), risedronate (Actonel), raloxifene (Evista), ibandronate (Boniva), calcitonin (Calcimar), and zoledronate (Reclast);
  • Medications that increase bone formation such as teriparatide (Forteo).

Currently, the most effective medications for osteoporosis that are approved by the FDA are anti-resorptive agents, which prevent bone breakdown. Anti-resorptive medications inhibit bone removal (resorption). They help rebuild bone and increase bone density. Menopausal estrogen hormone therapy is one example of an anti-resorptive agent. Others include alendronate (Fosamax), risendronate (Actonel), raloxifene (Evista), ibandronate (Boniva), calcitonin (Calcimar), and the recently approved zoledronate (Reclast).

Bisphosphonates, a class of drugs that inhibits the breaking down of bone, decrease the risk of hip fracture, wrist fracture, and spine fracture. To reduce side effects and to enhance absorption of the medicine, all bisphosphonates taken by mouth (orally) should be taken in the morning, on an empty stomach, thirty minutes before breakfast, and with at least 8 ounces (240 ml) of water (not juice). Taking the pill sitting or standing minimizes the chances of the pill being lodged in the esophagus. Patients should also remain upright for at least 30 minutes after taking the pill to avoid reflux of the pill into the esophagus. Also, no food or drink should be taken for at least 30 minutes afterwards. Newer intravenous bisphosphonates, such as ibandronate (Boniva) and zoledronate (Reclast) avoid these potential gastrointestinal problems.

Alendronate (Fosamax)

Alendronate (Fosamax) is a biphosphonate anti-resorptive medication. Alendronate is approved for the prevention and treatment of postmenopausal osteoporosis as well as for osteoporosis that is caused by cortisone-related medications (corticosteroid-induced osteoporosis). Alendronate has been shown to increase bone density and reduce fractures in the spine, hips, and arms. Alendronate is taken by mouth once-a-week to prevent and treat postmenopausal osteoporosis. Alendronate is the first osteoporosis medication also approved for increasing bone density in men with osteoporosis, either in a daily or a weekly dose schedule.

Alendronate is generally well tolerated with few side effects. One side effect of alendronate is irritation of the esophagus (the food pipe connecting the mouth to the stomach). Inflammation of the esophagus (esophagitis) and ulcers of the esophagus have been reported infrequently with alendronate use.

Risedronate (Actonel)

Risedronate (Actonel) is another bisphosphonate anti-resorptive medication. Like alendronate, this drug it is approved for the prevention and treatment of postmenopausal osteoporosis as well as for osteoporosis that is caused by cortisone-related medications (glucocorticosteroid-induced osteoporosis). Risedronate is chemically different from alendronate and has less likelihood of causing esophagus irritation. Risedronate is also more potent in preventing the resorption of bone than alendronate.

Ibandronate (Boniva)

Ibandronate (Boniva) is an oral bisphosphonate for prevention and treatment of postmenopausal osteoporosis. It is available in both daily and monthly oral formulas as well as intravenously every three months.

Zoledronate (Reclast)

Zoledronate (Reclast) is a unique yearly intravenous bisphosphonate anti-resorptive medication. This formulation seems to have very good bone strengthening ability by increasing bone density as well as significant fracture prevention both for spinal bone and bones away from the spine. Its convenience as given only once a year is obvious. As with all bisphosphonates, patients taking zoledronate (Reclast) must be loaded with adequate calcium and vitamin D prior to and after taking the medication for optimal results.

Generally patients are given acetaminophen the day of the infusion and for several days afterward to prevent occasional minor muscle and joint aching. The infusion lasts approximately 20-30 minutes.

A small number of cases of osteonecrosis of the jaw have been reported in people taking bisphosphonates for osteoporosis. Risk appears to be higher in those individuals who have received bisphosphonates intravenously and have primarily occurred after trauma to the jaw, such as tooth extraction, or cancer treatment.

Selective estrogen receptor modulators (SERMs)

Raloxifene (Evista)

Raloxifene (Evista) belongs to a class of drugs called selective estrogen receptor modulators (SERMs). SERMs work like estrogen in some tissues but as an anti-estrogen in other tissues. The SERMs are developed to reap the benefits of estrogen while avoiding the potential side effects of estrogen. Thus, raloxifene can act like estrogen on bone, but as an anti-estrogen on the lining of the uterus.

Because of its anti-estrogen effects, the most common side effects with raloxifene are hot flashes. Conversely, because of its estrogenic effects, raloxifene increases the risk of blood clots, including deep vein thrombosis (DVT) and pulmonary embolism (blood clots in the lung). The greatest increase in risk occurs during the first 4 months of use. Patients taking raloxifene should avoid prolonged periods of immobility during travel, when blood clots are more prone to occur. The risk of deep vein thrombosis with raloxifene is probably comparable to that of estrogen, about 2 to 3 times higher than the usual low occurrence rate. Raloxifene decreases the risk of spine fractures in postmenopausal women with osteoporosis, but the benefit in decreasing hip fracture risk is not yet known. (The only agents that are definitely proven to decrease hip fracture risk are bisphosphonates.)

Calcitonin (Calcimar, Miacalcin)

Calcitonin (Calcimar, Miacalcin) is a hormone that has been approved by the FDA in the United States for treating osteoporosis. Calcitonins come from several animal species, but salmon calcitonin is the one most widely used. Calcitonin can be administered as a shot under the skin (subcutaneously) or into the muscle (intramuscularly), or inhaled nasally (intranasally). Intranasal calcitonin is the most convenient of the three methods.

Calcitonin has been shown to prevent bone loss in postmenopausal women. In women with established osteoporosis, calcitonin has been shown to increase bone density and strength in the spine only.

Calcitonin is not as effective in increasing bone density and strengthening bone as estrogen and the other anti-resorptive agents. In addition, it is not as effective in reducing spine fracture risk, and has not been proven effective in reducing hip fracture risk.

Therefore, calcitonin is not the first choice of treatment in women with established osteoporosis. Nevertheless, calcitonin is a helpful alternative osteoporosis treatment for patients who cannot tolerate other medications.

Common side effects of either injected or nasal spray calcitonin are nausea and flushing. Patients using Miacalcin Nasal Spray can develop nasal irritations, a runny nose, or nosebleeds. Injectable calcitonin can cause local skin redness at the site of injection, skin rash, and flushing.

Teriparatide (Forteo)

Teriparatide (Forteo) is a synthetic version of the human hormone, parathyroid hormone, which helps to regulate calcium metabolism. It promotes the growth of new bone, while the other osteoporosis medications improve bone density by inhibiting bone resorption. Teriparatide (Forteo) is self-injected into the skin. Because long-term safety is not yet established, it is only FDA-approved for 24 months of use and works best in conjunction with a bisphosphonate. It reduces spine fractures in women with known osteoporosis, but reduction of hip fracture risk is currently unproven.

Check with your physician or pharmacist if you are unsure about a specific drug or formula.

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