For people who have more advanced osteoporosis, prescription medications, as well as lifestyle modifications, may be necessary to control and mitigate the disease.

When to Start Osteoporosis Medications

• In post-menopausal women and men >50 yrs old with
• T-score >2.5 and <-1.0 with a FRAX score of >20% for major osteoporotic fracture risk and .3% for hip fracture risk
• typical fragility fractures
• T-scores < -2.5,
  • Multiple risk factors; particularly those who already had fracture

The prescription drugs Alendronate, Risedronate, Ibandronate, and Zoledronic acid are the most commonly prescribed drugs in the treatment of this disease. They belong to a class of pharmaceuticals known as bisphosphonates. These medications are typically taken orally once a week or once a month or by injection once every year or once every three months.

Bisphosphonates : synthetic analogues of pyrophosphates. Reduce bone resorption and bone loss by binding to bone and poisoning active osteoclasts. Medication shows yearly bone density increases of 2-3% at the lumbar spine.

• Brands
  • Alendronate (Fosamax) 5mg/day for prevention, 10mg/day for treatment
  • Risedronate (Actonel) prevention and treatment dose in the same. 5mg/day, 35mg once a week, 75mg 2x a month, or 150mg once a month
  • Zoledronic Acid (Reclast) 5mg IV once yearly
• Instructions: take on an empty stomach with 6-8oz of water and 30mins before meals, other medications, or laying down
• Side effects include nausea, abdominal pain, difficulty swallowing, and the risk of an inflamed esophagus or esophageal ulcers. Injected forms of bisphosphonates don’t cause stomach upset. Adverse effects with long long term use: over suppression of bone turnover, osteonecrosis of the jaw, unusual fractures.
  • “May 2012, important update by the FDA expressed concerns about the safety and effectiveness of bisphosphonate use beyond 3 to 5 years”
  • Consider switching to another osteoporosis therapy after 5years on Bisphosphonates for those at moderate risk of osteoporotic fracture and after 10 years for those at high risk. Avoid in those at low risk of fracture.
• Contraindications: disorders of esophageal motility or active GI bleeding, hypocalcaemia, untreated vitamin D deficiency, and renal disease

Raloxifene, Teriparatide, and Denosumab are typically prescribed for advanced cases of osteoporosis and when other remedies, like improved lifestyle or hormone replacement, fail.

Raloxifene (Evista) Selective estrogen receptor modulator acts as an estrogen receptor agonist on the skeletal but as an antagonist on the breast and uterine tissue

• For postmenopausal osteoporosis prevention and treatment at 60mg/day
• Show 1.5-3% increase bone density in spine and femoral neck density and 30% decrease in new vertebral fractures. No reduction in nonveterbral fractures
• Adverse effects: hot flashes, venous thromboembolic disease, fatal stroke, leg cramps

Teriparatide PTH analogue that stimulates bone formation and increase bone remodeling rates (increases bone mass)

• Given SQ is shown to increase bone density at the hip and spine by 2-8% after one year in postmenopausal women and in both men and women receiving glucocortoid therapy
• Approved for 2years of use
• There is rapid loss of bone density gains after cessation. Alendronate therapy after PTH use helps maintain and increase bone density
• Retreatment with PTH use after Alendronate therapy may provide additional bone density gains
• Teriparatide is generally used only for severe osteoporosis, because most people don’t want to get shots every day and it’s also very expensive
• Side effects can include nausea, leg cramps, and dangerously high calcium levels
• Contraindicated in those with hypercalcemia and those at risk for osteosarcoma

Denosumab : monoclonal antibody that inhibits RNAK ligand and potently reduces bone resorption

• Given SQ 60mg every 6 months
• Approved for postmenopausal women
• Contraindication: hypocalcaemia
• Adverse effects: back and muscle pain, serious infections (of the skin), hypocalcaemia, osteonecrosis of the jaw, significant suppression of bone turnover

Pharmaceutical estrogen , which replaces the estrogen lost during menopause, is sometimes prescribed for women undergoing menopause. It is not the first treatment of choice for osteoporosis, but it can be effective in mitigating bone loss if prescribed for other menopausal symptoms.

Estrogen only for prevention. Inhibits bone resorption, decreases bone remodeling, and enhances absorption of calcium

• Once estrogen therapy stopped bone loss resumes at same rate as untreated
• Long term use places those at risk for breast cancer
• Contraindications: undiagnosed vaginal bleeding, pregnancy, active thrombosis, active liver disease, endometrial adenocarcinoma, breast cancer, other estrogen depend tumors

Similarly, osteoporosis in men can be treated by testosterone replacement though the therapeutic value of testosterone needs more study.

Parathyoid- thyorid axis Hormone replacements

Calcitonin produced by the thyroid gland, is a peptide hormone that appears to slow bone loss and temporarily increase vertebral bone mass by decreasing osteoclastic activity

• Shown to prevent fractures of the spine but not of the hip and wrist
• Has the most analgesic properties and can help in the treatment of vertebral fracture pain
• Not advised to be used alone
• Dosing
• 50-100 units/day 3x per week for injection
• 200 units/day alternating nostrils

What medications are used to treat osteoporosis will depend on your age, symptoms, and current health.