Andrea Singer, MD
Andrea Singer, MD, division director of Women’s Primary Care and of bone densitometry at MedStar Georgetown University Hospital in Washington, D.C. and clinical director of the National Osteoporosis Foundation.
Bottom Line: Why these notorious drugs may still be the best way for you to prevent a fracture.
When you have osteoporosis, the risk of falling and breaking a bone is a big deal. A fracture can cost you your independence and even lead to death. One way to protect your bones is with medication, but there’s the notorious problem with bone drugs: Some research has linked certain ones to side effects that are rare, but scary just the same (more on these below). As you can imagine, that’s been enough to make many people shy away from taking osteoporosis drugs…and make doctors reluctant to prescribe them.
This is not good. In a boomerang effect, the incidence of hip fractures has been on the upswing since 2013, according to a study published in Osteoporosis International. Making matters worse, fewer people are getting tested for osteoporosis—they may not have access to testing facilities or their health care provider may not have talked to them about for bone density concerns. Perhaps some figured they wouldn’t want to take any of the drugs they’ve heard about even if they tested positive. But if people aren’t tested and diagnosed, they can’t be treated at all, and life-ruining fractures become more likely.
What’s the answer for you? First, know that osteoporosis drugs are not as dangerous as most of the media, Internet chat groups and popular opinion would have you believe. The risks do vary from drug to drug and from patient to patient. So the wise thing to do is to learn the facts about osteoporosis drugs and clarify your unique risks and benefits with your doctor to get on the right bone-strengthening course—whether with or without drugs—for you. You’re in the right place, because that’s exactly what we’ll help you do.
The first thing to know is that there are two main kinds of osteoporosis drugs…
Antiresorptives. Your body normally breaks down old bone and resorbs, or releases, its minerals into your bloodstream. At the same time, your body builds new bone (a process called remodeling). As you get older, your bone may be broken down faster than it is rebuilt. Antiresorptive therapies slow the body’s normal breakdown of bone to reduce the risk of fractures. Antiresorptives include bisphosphonate and non-bisphosphonate drugs. Bisphosphonates include alendronate (Fosamax), risedronate (Actonel, Atelvia), ibandronate (Boniva) and zoledronic acid (Reclast).
The most effective non-bisphosphonate antiresorptive is denosumab (Prolia), an antibody that inhibits cells that cause the breakdown of bone.
Another antiresorptive option is raloxifene (Evista). Known for its role in breast cancer treatment, it mimics estrogen to decrease the turnover of bone.
Anabolics. Recommended for people who’ve already had a fracture or are at high fracture risk, these drugs work by stimulating the creation of new bone (as opposed to the antiresorptives that stop bone lossteriparatide (Forteo) and abaloparatide (Tymlos), both synthetic versions of parathyroid hormone.
There are three main considerations when weighing osteoporosis drugs: effectiveness, common side effects and serious side effects. By knowing each of these aspects, you’ll be in a better position to discuss the pros and cons with your doctor…
Effectiveness: Both antiresorptive and anabolic therapies are very effective at reducing the incidence of fractures of the spine, hip and other nonvetebral sites, which is the main therapeutic goal. Examples: Bisphosphonates can reduce the risk of spinal fracture by 55% and of any type of fracture by 62%, according to a research review published in Journal of Bone Metabolism. The non-bisphosphonate antiresorptive denosumab not only stops the resorption of bone, but helps to build back bone density as well. Some studies have found that the anabolic medications may be even more effective at preventing fractures than some bisphosphenates.
Common side effects: All osteoporosis medications can cause muscle and bone aches or pains. These are generally mild and lessen over time. Side effects when bisphosphonates are taken orally (as Fosamax, Actonel and Atelvia must be) can include abdominal pain, nausea and esophagus irritation. You are less likely to experience these if you take the medications correctly—on an empty stomach first thing in the morning with a full glass of water. Then, don’t lie down, bend over or eat for 30 to 60 minutes, depending on the specific drug, to keep the medicine from coming back up the esophagus. These side effects also often go away over time.
Dangerous side effects: There are certain serious events linked to osteoporosis drugs.
There is the possibility that taking a bisphosphonate or denosumab can lead to osteonecrosis, or bone death, of the jaw. Typically what happens is that a portion of the jaw bone that has been exposed as a result of invasive dental work, such as a tooth extraction or implant, fails to heal and then degrades. You may have seen reports that this can happen in up to 8% of people taking the drugs, but that number, while accurate, is skewed by one particular patient group: people being treated with bisphosphonates for bone cancer. Among people without bone cancer who take bisphosphonates, the incidence of osteonecrosis is currently thought to range from one in 10,000 to 1 in 100,000—meaning, from 0.01% to 0.001%.
What to do: For your maximum safety and peace of mind if you take a bisphosphonate, even if you have not been diagnosed with bone cancer, if you need to have a dental procedure, talk to both the doctor in charge of your osteoporosis care and your dentist or oral surgeon about how to reduce your risk. If you haven’t started osteoporosis medication yet, have any dental issues addressed first. Once you’ve started your drug treatment, follow all preventive dental hygiene measures to avoid problems. And should any occur, discuss the least invasive dental procedures available to you.
Bisphosphonates and denosumab have also been linked to atypical femoral fractures—thigh bone breaks not caused by an obvious accident, for instance. According to one study, while 80% of women with this type of break were on bisphosphonates, the absolute number of women experiencing such a fracture while on one of these drugs is small—less than 0.002%. Bisphosphonate treatment must be stopped if you have a fracture, but the anabolic drug teriparatide, along with calcium and vitamin D, has been shown to help with healing after surgery to repair the break.
Less certain is the association between bisphosphonates and the irregular heartbeat condition called atrial fibrillation. An Italian study of more than 122,000 people on these drugs found that 0.6% developed afib during the followup period. An American study found that the risk was greater with IV bisphosphonates than with oral ones.
Other potential risks to be aware of: Because of an increased risk of blood clots, the hormonal antiresorptive raloxifene isn’t recommended for people at increased risk for or with a history of blood clots.
As for the anabolic medicines, teriparatide and abaloparatide have been associated with osteosarcoma, a rare bone cancer, in studies done on rats. It’s important to note that the rats were exposed to much higher doses than are used in people and for longer periods than the two-year human prescribing limit. Osteosarcoma has not been seen in people taking these drugs. A 15-year study looking for any association between teriparatide and osteosarcoma is nearing completion, but none was found at the halfway point. Just to be safe, though, if you have an underlying condition that puts you at risk for osteosarcoma—such as other bone diseases like Paget’s or a history of bone cancer or metastatic cancer to the bone, for example—it’s best to avoid these medications.
Also, anabolics can raise calcium levels in your body as a consequence of increasing bone mineral levels. This, in turn, can increase the risk for kidney stones (drinking plenty of water helps avoid this), so they aren’t recommended for people with a recent history of kidney stones.
The bottom line: It seems clear that osteoporosis drugs fall within widely accepted zones of risk-vs-benefit for many people…but which drug is best can vary widely from person to person. Don’t reject the idea of using one of these drugs only based on worst-case scenarios that have happened to some other people—instead, talk with your doctor about whether the risk for a fracture from osteoporosis is greater than risk from the available medications for you.
