Osteoporosis medications

By: Scott Boden, MD
August 29, 2006

If a DEXA scan shows bone loss, the treating physician may prescribe an osteoporosis medication. These medications work to either slow/stop further bone loss or to increase bone formation.

The choice of osteoporosis medication to prescribe is based on a number of variables, including the gender of the patient, the type of osteoporosis (primary or secondary), the age of the patient, the number of years a female patient is post-menopause, and the preferred method of drug administration (by mouth, by injection, etc.). Currently, the medications approved by the U.S. FDA for the prevention and/or treatment of osteoporosis include:

• Bisphosphonates – e.g., Alendronate (e.g., brand name Fosamax), Ibandronate (e.g., brand name Boniva), Risedronate (e.g., brand name Actonel).

  • Alendronate is approved for the prevention and treatment of postmenopausal osteoporosis. Alendronate also is approved for treatment of glucocorticoid-induced osteoporosis in men and women and for the treatment of primary osteoporosis in men. It is taken orally once per day or once per week.

  • Ibandronate is approved for the prevention and treatment of postmenopausal osteoporosis. It is taken as a once-a-month pill.

  • Risedronate is approved for the prevention and treatment of postmenopausal osteoporosis. It is also approved for use by men and women to prevent and/or treat glucocorticoid-induced osteoporosis. It is taken orally once per day or once per week.

  Side effects for bisphosphonates are generally mild to moderate and usually do not require stopping treatment, such as gastrointestinal problems (e.g., constipation, difficult or painful swallowing, chest pain), abdominal or musculoskeletal pain (e.g., joint pain, back pain), nausea, heartburn, or irritation of the esophagus. Serious side effects, while rare, can include osteonecrosis of the jaw (death of bone tissue, which can result in toothache, loose teeth, jaw pain, etc.) and of visual disturbances – these issues should be reported to the healthcare provider immediately.⁶
  
  To avoid damage to the esophagus and to ensure that food or other oral medication doesn’t interfere with absorption, bisphosphonates should be carefully taken according to the instructions. These instructions include taking the drug in the morning upon waking and during a specific time period before eating. The drug should be taken with a glass of water, and the person should remain upright for a specific time period after taking it. These drugs should not be taken by people who cannot stand or sit upright or who have disorders that prevent esophageal emptying into the stomach.⁷

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• Calcitonin – e.g., Miacalcin, Calcimar, Fortical. Calcitonin is a naturally occurring hormone involved in calcium regulation and bone metabolism. It is approved for use in postmenopausal women, and is taken as an injection or nasal spray.
  
  Calcitonin taken as an injection may cause an allergic reaction. A skin rash or hives requires medical attention. Other side effects may occur and should subside as your body adjusts to the medicine; a doctor should be consulted if these symptoms persist or are bothersome: diarrhea; flushing or redness of face, ears, hands, or feet; loss of appetite; nausea or vomiting; pain, redness, soreness, or swelling at place of injection; stomach pain; increased frequency of urination; chills; dizziness; headache; pressure in chest; stuffy nose; tenderness or tingling of hands or feet; trouble in breathing; weakness. Side effects for calcitonin taken by nasal spray are uncommon but may include nasal irritation, backache, bloody nose, and headaches.⁸

• Estrogen/hormone therapy – either estrogen alone (e.g., Estraderm, Ogen, Premarin) or estrogen and progestin (e.g., Activella, FemHrt, Prempro) are used together to manage symptoms of menopause. They have also been shown to decrease the risk of fractures in the hip and spine in postmenopausal women. However, given recent findings that certain types of hormone replacement can increase a patient’s risk of certain cancers, stroke or heart attack, patients are currently advised to consider other osteoporosis medications.

• Selective Estrogen Receptor Modulators – Raloxifene (e.g., Evista). This class of drugs was developed to provide the benefits of estrogens without their disadvantages. Approved for postmenopausal osteoporosis, Raloxifene is taken orally once a day.
  
  Most side effects of Raloxifine are mild, and include hot flashes and leg cramps. A rare but serious side effect is blood clots in the veins (deep vein thrombosis). A physician should be notified immediately if the patient has pain in the calves (lower part of legs), leg swelling, sudden chest pain, shortness of breath, if coughing up blood, or if changes in vision occur.⁹

• Parathyroid hormone – Teriparatide (e.g., Forteo), the only approved treatment for osteoporosis that increases bone formation (rather than slows bone loss). It is approved for the treatment of osteoporosis in postmenopausal women and men who are at high risk for a fracture. Teriparatide is self-administered as a daily injection for up to 24 months.
  
  The most common side effects of teriparatide include nausea, leg cramps and dizziness. They may also include: pain, headache, weakness, diarrhea, and depression. A doctor should be notified if any of these symptoms are severe or do not go away. While rare, more serious side effects can occur, and medical help should be sought immediately if any of the following occur: chest pain; fainting; difficulty breathing; fever, sore throat, chills, and other signs of infection; upset stomach; vomiting; constipation; lack of energy; or muscle weakness.
  
  Forteo carries a strong caution from the FDA. In the pre-approval studies of Forteo using rats, there was an increase in the incidence of osteosarcoma, a rare but serious cancer of the bone. It is possible that people treated with Forteo could be at increased risk for developing this cancer. Patients are advised to speak with their doctors about the risks of taking this medication. Because of this risk, teriparatide is usually not used to prevent osteoporosis, to treat mild osteoporosis, or by people who can take other medications for osteoporosis. Patients should not use teriparatide unless they have osteoporosis and at least one of the following conditions is met: they have already had at least one bone fracture; their doctor has determined that they are at high risk of fractures; or they cannot take or do not respond to other medications for osteoporosis. Patients should tell their doctors if they have or have ever had a bone disease such as Paget's disease, bone cancer or a cancer that has spread to the bone, or radiation therapy of the bones. The doctor can order certain tests to see if teriparatide is appropriate for the individual. People who are prescribed Forteo should receive an FDA-approved medication guide that explains the benefits and risks and gives other advice about how to use the treatment properly.¹⁰

Scott Boden, MD
August 29, 2006