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Osteoporosis Medicines

Osteoporosis Medicines

As anyone who has seen commercials during the evening news already knows, osteoporosis medications are a big business. Doctors and patients have several options to choose from, each with their own pros and cons. All of them are intended to prevent fractures by increasing the density of the bones.

Do I need to take medications for osteoporosis?

If you’re over 50, there’s a good chance that your bones need help. Over half of all Americans in their 50s and older have osteoporosis, a condition that robs bones of calcium and other minerals, leaving bones weak, brittle, and vulnerable to breaks. The body engages in a continuous process of building and removing bone tissue to maintain a healthy density. In your prime, buildup keeps up with removal, but with age, loss may outstrip replenishment. While it’s possible to strengthen bones by practicing regular weight-bearing exercise and getting extra calcium and vitamin D, these lifestyle changes alone may not be enough to counter osteoporosis or keep your bones from breaking.

In the fall of 2008, the American College of Physicians released new guidelines for treating osteoporosis. The message: If tests show that you have weak bones or if your bones are already breaking from osteoporosis, you probably need to be taking a prescription medicine. However, no current treatment can fully cure osteoporosis. No matter which drug you take, you’ll never recover the bone density you had in your 20s or 30s, but you may be able to halt or reverse a certain amount of the loss in strength and density. To give yourself the best possible protection against broken bones, you may need medication for the rest of your life.

What are the different types of osteoporosis medications?

As anyone who has seen commercials during the evening news already knows, osteoporosis medications are a big business. Doctors and patients have several options to choose from, each with their own pros and cons. All of them are intended to prevent fractures by increasing the density of the bones. Some are better-studied than others, and evidence suggests that one class of drugs — bisphosphonates — may be an especially good first choice.

Bisphosphonates. These are oral medications that slow the breakdown of bone by interfering with the activity of specialized cells called osteoclasts, which break down and absorb the minerals in bones. Examples include Fosamax (alendronate), Actonel (risedronate), and Boniva (ibandronate). As a group, bisphosphonates have been well studied. Two drugs stand out: Fosamax and Actonel. Both have shown dramatic results in preventing breaks, including fractures of the hip and spine.

As reported in the Annals of Pharmacotherapy in 2005, a three-year study of patients who had already suffered broken bones from osteoporosis found that a daily dose of Fosamax cut in half the risk of further breaks in the hip or spine. A three-year study of women with osteoporosis found that taking Actonel every day cut the risk of hip fractures by 40 percent. Another study found that taking Actonel just once a week for a year reduced spine fractures by nearly 80 percent. A 2008 report in the Annals of Internal Medicine concluded that both Fosamax and Actonel are highly effective treatments in preventing non-spinal fractures. Fosomax is also available in generic form as alendronate.

Boniva can greatly reduce spinal fractures, but it is uncertain whether it helps to prevent other types of fractures. Boniva is taken as one high-dose pill each month.

Bisphosphonates do have side effects, which can vary among the different drugs. They can cause mild cases of acid reflux, heartburn, or nausea. Some patients also develop ulcers in the esophagus.

There’s growing evidence that the drugs also increase the risk of necrosis (death) of bone tissue in the jaw, a rare complication that can cause severe and sometimes disabling pain. In 2008, the Food and Drug Administration (FDA) warned doctors to watch for such complications in patients taking bisphosphonates. As these drugs act by modifying the bone breakdown and repair process, researchers suspect that long-term use may hinder microfracture repairs, but the newer drugs appear to be safer.

In very rare cases, this bone repair complication can affect healing after oral surgeries in people who have been on bisphosphonates, especially those who receive their medicine intravenously or who have been taking an oral bisphosphonate for several years. If you have invasive dental work coming up (such as extractions or other procedures involving the jawbone), try to have it done before you start taking bisphosphonates. Practicing good oral hygiene and having regular dental checkups is the best way to prevent problems that might require oral surgery.

Miacalcin (calcitonin). Calcitonin is a natural hormone that slows bone loss while encouraging the buildup of new bone tissue. Delivered through a nasal spray, it can definitely make bones denser, but there’s only moderate evidence that it can prevent spine fractures. It hasn’t shown a strong protective effect on bones in other parts of the body, either. However, the drug doesn’t seem to cause any significant side effects, and it could be a good backup option for patients who have bad reactions to bisphosphonates.

Evista (raloxifene). This drug works by mimicking some of the actions of the hormone estrogen. Evista can prevent fractures in the spine but doesn’t seem to protect the hip. The drug can cause hot flashes and may slightly increase the risk of blood clots, leg cramps, swelling, flu-like symptoms, chest pain, and abnormal heart rhythms. Women at high risk for stroke should not take this drug. On the positive side, Evista has been FDA approved as a preventive measure against invasive breast cancer, so it may be a good option for women at high risk for the disease.

Forteo (teriparatide). This drug can dramatically improve bone density and prevent fractures all over the body, but it has some significant drawbacks. It can be extremely costly, and patients have to inject it every day. Also, laboratory studies have found that the drug can cause bone cancer in rodents. Although there are no such reports in humans, doctors take the risk seriously, so patients aren’t allowed to take the drug for more than two years. For these reasons, Forteo is generally reserved for the most severe cases of osteoporosis.

Hormone replacement therapy. Postmenopausal women who receive hormone replacement therapy (including estrogen or combinations of estrogen and progestin) enjoy some protection against fractures in the spine, hip, and other parts of the body. But HRT can also increase the risk of blood clots, stroke, and estrogen-progestin treatments can increase the risk of breast cancer. Some experts no longer recommend it as a first-line treatment for osteoporosis, given that other drugs are so effective. The FDA recommends that other medications besides HRT be used to prevent post-menopausal osteoporosis, unless the woman cannot take non-estrogen therapy. In that case, estrogen should be taken at the lowest possible dose for the shortest period of time.

If I’m taking a medication, do I still need extra calcium and vitamin D?

No matter what prescription you’re taking, you’ll need plenty of calcium and vitamin D (which helps absorb the calcium) to give your bones maximum protection. If you’re over 50, you should try to get at least 1,200 milligrams of calcium and 800 to 1,000 IU of vitamin D every day. Try to get as much of your calcium from food as possible; good sources include dairy, bony fish, dark greens, and certain fruits, vegetables, and nuts. Many brands of orange juice, tofu, and cereals are also fortified with calcium. If you are not sure whether you are getting enough vitamin D with your current supplements, you can ask your doctor to give you a blood test. Many people with osteoporosis are surprised to learn that they have a vitamin D deficiency even though they have been taking vitamin D supplements.

A supplement can be useful if you’re not able to get enough calcium-rich foods, but remember the calcium in most supplements (calcium carbonate) is usually not in a form the body can absorb easily, and may cause constipation. Calcium citrate supplements often cost more but will be absorbed more easily. Keep in mind, your body can only absorb up to 500 mg of calcium at a time, so you may need to divide your dosage over the day if you’re taking much more than that. Lastly, always check with your doctor before taking any new supplements.

Can any medications prevent osteoporosis in the first place?

If your doctor says you’re at risk for osteoporosis — perhaps because you have a family history or because tests show your bones are starting to thin — a prescription could help you avoid significant bone loss. The FDA has approved several medications for osteoporosis prevention, including Fosamax, Actonel, Boniva, and Evista.

References

Qaseem, A. et al. Pharmacologic treatment of low bone density or osteoporosis to prevent fractures: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine. 2008. 149(6): 404-415.

Cadarette, S.M. et al. Relative effectiveness of osteoporosis drugs for preventing nonvertebral fracture. Annals of Internal Medicine. 2008. 148 (9): 637-646.

Gold, D.T. Patient preference and adherence: comparative US studies between two bisphosphonates, weekly risedronate or monthly ibandronate. Current Medical Research and Opinion. 2006. 22(12): 2383-2391.

U.S. Food and Drug Administration. FDA approves new uses for Evista. 2007. www.fda.gov/bbs/topics/NEWS/2007/NEW01698.html

Mayo Clinic. Osteoporosis drug therapy. www.mayoclinic.org/specialty-pharmacy/osteoporosis.html#role.html

The Annals of Pharmacotherapy. For our patients. Discovery, clinical development, and therapeutic uses of bisphosphonates. 2005. www.theannals.com/cgi/data/aph.1E357/DC1/1

University of British Columbia Public Affairs. Media release: Popular osteoporosis drugs triple risk of bone necrosis. Jan 15, 2008. www.publicaffairs.ubc.ca/media/releases/2008/mr-08-004.html

Etminan, M., K. Aminzadeh,I.R. Matthew, et al. Use of oral bisphosphonates and the risk of aseptic osteonecrosis: a nested case-control study. Journal of Rheumatology. 2008 Apr;35(4):691-5.

Medscape Ob/Gyn and Womens Health. When to use teriparatide. 2003. www.medscape.com/viewarticle/464171

National Institutes of Health Office of Dietary Supplements: Calcium Factsheet http://ods.od.nih.gov/factsheets/calcium.asp

National Institutes of Health Office of Dietary Supplements: Vitamin D Factsheet http://ods.od.nih.gov/factsheets/vitamind.asp

Mayo Health Letter http://healthletter.mayoclinic.com/editorial/editorial.cfm/i/96/t/Building%20blocks%20of%20bone/

UC Berkeley Wellness Letter http://www.wellnessletter.com/html/ds/dsCalcium.php

American Academy of Orthopaedic Surgeons. Osteoporosis prevention. http://orthoinfo.aaos.org/topic.cfm?topic=A00315

Coxon, F.P., K. Thompson, A.J. Roelofs, et al. Visualizing mineral binding and uptake of bisphosphonate by osteoclasts and non-resorbing cells. Bone. Vol 24 Issue 5 p. 848-860. May

Ott. S.M. Long-term safety of bisphosphonates. Journal of Clinical Endocrinology and Metabolism. Vol 90 No 3 1897-1899.

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National Osteoporosis Foundation. Osteoporosis medications. www.nof.org/patientinfo/medications.htm

American Dental Association (ADA). Osteonecrosis of the jaw www.ada.org/public/topics/osteonecrosis.asp

Capsoni, F. et. al. Bisphosphonate-associated osteonecrosis of the jaw: the rheumatologist’s role Arthritis Res Ther. 2006; 8(5): 219 www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1779450

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