Osteoporosis Medications: What Are Your Options?

Having osteoporosis can put you at risk for fractures. And that’s a road you don’t want to go down if you can avoid it.

But what medications can help manage osteoporosis? And what can you expect from them? Rheumatologist Linda Mileti, MD, shares what you need to know about osteoporosis medications.

Is there a ‘best’ medication for osteoporosis?

There’s no one osteoporosis medication that’s best for everyone. What your provider ultimately recommends will be based on choosing what’s likely to work best for your needs. That includes considering factors like your bone density and whether you’ve had a history of conditions like:

• Fractures
• Cancer
• Kidney disease
• Heart disease
• Severe heartburn
• Menopause symptoms
• Heart events, like heart attack or stroke

Things like vitamin D and calcium supplements may be enough if you have osteopenia, a warning sign that you may be on your way to osteoporosis. But if you cross the threshold to osteoporosis, it’s time for prescription medication. Dr. Mileti shares which medications may be recommended and why.

Bisphosphonates

Bisphosphonates are some of the most common osteoporosis medicines. They’re a class of osteoporosis medications that are called “anti-resorptives.” They help slow the breakdown of bone in your body.

“Our bodies constantly break down and rebuild bone. That’s normal and healthy,” Dr. Mileti explains. “But when you have osteoporosis, you can start breaking down more than you rebuild.”

Some of the most common oral bisphosphates include alendronate (Fosamax®) and risedronate (Actonel®). Zoledronic acid is a common IV (intravenous) bisphosphonate. It goes by the brand names Reclast® and Zometa®.

Pros

• Effective: Research has proven they’re really effective at slowing bone breakdown for most people. And they’re generally well tolerated. They’re shown to improve bone density and prevent fractures in people with osteoporosis.
• Options: They’re available as oral medications that you take once a week or once a month and as IV formulations that you get from a healthcare provider once a year.

Cons

• Not recommended for kidney disease: If your kidneys aren’t functioning well, they may not be able to eliminate the medications from your body.
• Esophagus irritation: Oral bisphosphates can irritate your esophagus and cause acid reflux. That’s why you’re encouraged not to lie down for about 30 minutes after taking your dose. It’s also why they’re typically not the best choice for people with severe heartburn or Barrett’s esophagus.
• Flu-like symptoms: IV bisphosphates can leave you run down for a bit. “Sometimes, you can get an infusion reaction, which essentially feels like a mild flu,” Dr. Mileti notes. “It typically lasts just a day or two.”
• Lower blood calcium levels: When taking bisphosphonates, it’s important to get enough calcium in your diet, or take supplements as recommended by your provider.
• Rare side effects: In very rare cases, taking bisphosphonates can cause osteonecrosis of the jaw (which causes parts of your jaw bone to die) and atypical femur fracture (a break just below your hip). To help reduce those risks, most providers will recommend taking regular “holidays” from bisphosphonates.

Denosumab (Prolia®)

Denosumab is a type of injectable medication for osteoporosis. It’s given every six months.

Like bisphosphonates, denosumab is an anti-resorptive medication — it works to slow bone breakdown.

Pros

• Safe for kidney disease: That’s an advantage over bisphosphonates.
• Safe and effective: It’s well tolerated for most people, works well long-term, improves bone density and prevents fractures.
• Lower risk for rare side effects: “Like bisphosphonates, denosumab can cause osteonecrosis of the jaw and this atypical femur fracture — and, again, they’re very rare. But with denosumab, that risk doesn’t increase with time. There’s a little bit of a risk, and it stays stable,” Dr. Mileti reports.

Cons

• No stopping: “When you stop, you can lose a lot of bone density and fracture pretty easily,” Dr. Mileti warns. “When we give this medicine, it’s typically something we’re going to do for life. Or we’ll switch to a bisphosphonate to prevent the rebound bone loss that occurs with stopping Prolia.” But if you’ve been taking denosumab for many years, switching may not be enough to keep your bones strong.
• Lower blood calcium levels: Denosumab can also lower your blood calcium levels, so getting enough calcium is important.

Parathyroid hormone (PTH) analogs

Parathyroid hormone analogs are in a class of medications called anabolic agents.

Here’s what makes them different.

While bisphosphonates and denosumab work to slow down the process of bone breakdown, anabolic agents work on the other side of the coin. They help to build new bone.

PTH analogs like teriparatide (Forteo®) and abaloparatide (Tymlos®) are synthetic versions of parathyroid hormone. That’s a hormone that helps to control calcium in your body. More parathyroid hormone means more calcium, which means more bone-building power.

PTH analogs are injection medications that you give yourself once a day. Most people take these medications for two or three years.

Pros

• Build bone quickly: PTH analogs are a good choice for people who’ve had a fracture. They also can be very effective for people who have very low bone density.
• Best if you’re newly diagnosed: “We see these medicines as being most effective for people who haven’t already been taking a bisphosphonate or denosumab,” Dr. Mileti recommends.

Cons

• Not a stand-alone treatment: After finishing your course, you’ll need to start on an anti-resorptive medication, like bisphosphonate or denosumab. “If you don’t do anything further, you’ll lose the ground you gained,” Dr. Mileti points out.
• Calcium overload: PTH analogs can raise blood calcium levels. Talk with your provider about your calcium intake, including supplements, if you’re prescribed a PTH analog.
• Bone cancer risk: You may not be a good candidate for PTH analogs if you have risk factors for osteosarcoma (bone cancer). That includes a history of radiation treatment or Paget’s disease. Some non-human studies suggest PTH analogs may further increase that risk, but in humans, the incidence of bone cancer isn’t higher in people on PTH analogs compared to those who aren’t.

Romosozumab (Evenity®)

Romosozumab is another kind of anabolic agent. Like PTH analogs, it helps build bone. It’s one of the newest osteoporosis medications to hit the market.

Pros

• Short course: “Romosozumab is given as a pair of office injections once a month for a year,” Dr. Mileti explains.

Cons

• Not a stand-alone treatment: Romosozumab can fuel bone growth, but it needs to be followed up with a bisphosphonate or denosumab to maintain your bone strength.
• Potential heart risk: The research so far is mixed, but some studies suggest that it may slightly increase your risk of having a cardiovascular event. “We don’t have a definitive answer yet, so in the meantime, it’s probably better to avoid using this medication if you’ve had a heart attack or stroke,” Dr. Mileti advises.

Hormone Replacement Therapy (HRT)

In the past, hormone replacement therapy was a common treatment for osteoporosis for postmenopausal women. But as we’ve learned more about HRT and targeted osteoporosis medications have become available, it hasn’t been used as much for osteoporosis.

Pros

• Double duty: HRT can be used to help manage symptoms of menopause, like hot flashes, mood swings and vaginal dryness while addressing bone health.
• Estrogen boost: Estrogen helps keep your bones strong. So when your estrogen levels drop as you enter menopause, it can put you at increased risk for osteoporosis. HRT helps replace those lost hormones.

Cons

• Not for everyone: HRT should only be considered for postmenopausal women.
• Breast cancer risk: Some studies suggest HRT may slightly increase your risk of breast cancer. So, again, it’s not for everyone.
• Not a targeted treatment: HRT doesn’t address bone health specifically. “If you need hormone replacement therapy for menopausal symptoms, it certainly can help your bones,” Dr. Mileti acknowledges. “But we generally don’t use it specifically for bone health.”

Additional tips for managing osteoporosis

Even with the osteoporosis medications available, a healthy lifestyle is still an important factor to keep your bones strong.

Dr. Mileti stresses the importance of exercise, specifically weight-bearing exercise.

“Your bones need the compressive force from walking and standing,” she adds. “That’s why astronauts can get osteoporosis — they don’t have gravity pressing on their bones.”

Aim for exercises that encourage you to stand, like

• Walking
• Running
• Standing strength training
• Balance-building exercise

Talk with your healthcare provider to find the right exercise program to strengthen your bones to get the most benefit from your osteoporosis treatment.