Why the Benefits of Osteoporosis Drugs Outweigh the Risk of Rare Side Effects

Putting risks into perspective

Woman reading her medication bottle

Hesitating to take a drug your doctor has prescribed for osteoporosis or osteopenia because you’ve heard about alarming side effects? There’s important information you need to know, which should help provide some perspective.


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“You are more likely to suffer a bone fracture from untreated low bone density than you are to have one of the rare side effects from taking a drug,” says Chad Deal, MD, Head of the Center for Osteoporosis and Metabolic Bone Disease.

Bone fractures in an older adult increase the risk for loss of independence and even dying prematurely. A recent study found that older adults who break a bone have an increased risk for death that lasts for up to 10 years after the fracture.

In a troubling trend over the last several years, the rate of hip fractures among older women is on the rise. Another startling finding: Even after a hip fracture, many people aren’t taking osteoporosis drugs.

Understanding osteoporosis drugs

The most commonly prescribed osteoporosis drugs are bisphosphonates, which include alendronate (Fosamax®), risedronate (Actonel®), zoledronic acid (Reclast®) and ibandronate (Boniva®).

Bone constantly renews itself. Older bone is broken down and removed (resorbed) and new bone forms. As we age, bone density decreases because more bone is broken down than is newly formed. The bisphosphonate drugs work by slowing down bone resorption. Taking these medications reduces the likelihood of having fragility fractures.

The most common side effects of bisphosphonate drugs are minor stomach problems, such as heartburn, which affect up to 10 percent of people. Switching to a different bisphosphonate usually takes care of the problem.

The side effects people fear most are deteriorating jawbones (osteonecrosis of the jaw) and atypical thigh bone (femur) fractures. However, these are quite rare.

Minimizing jawbone problems

Only one in 50,000 people who take the drugs develop jawbone problems. Factors that make this more likely are known, so the risk can be minimized.

Most osteonecrosis of the jaw occurs in people with certain types of cancer who take very high doses of bisphosphonates. For people who don’t have cancer and develop a deteriorating jawbone, the problem often was preceded by a dental procedure involving cutting bone (such as a tooth extraction).

Before prescribing a bisphosphonate, we get a dental history and find out if any oral surgery is planned. Any needed procedures should be done before starting the drug.

When ‘drug holidays’ are a good idea

The other concern with bisphosphonates is a risk for atypical femur fractures. These almost never occur in the first three years of using the drugs. But because of the increasing risk over time, it has become standard to consider a “drug holiday.”


After three to five years of taking a bisphosphonate, your doctor may recommend stopping the drug for two years, based on an assessment of your risk for bone fractures.

A drug holiday may lower your risk for the unusual type of femur fracture, but be sure to go back on the drug when instructed by your doctor. Prolonged drug holidays have been shown to increase risk for the more common types of bone fractures.

“People should not allow fear to guide their decisions,” says Dr. Deal. “The benefits of bisphosphonates far outweigh the risks.”


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