Posted by Dr. Paul Utrie
Medications specifically for the treatment of fragile bones were introduced in the mid-1990s. Prior to this, estrogen replacement therapy was the only viable option for prevention and treatment. Due to concerns regarding estrogen replacement safety, these medications have become even more important. Their use has revolutionized our ability to legitimately reduce fracture risk.
If you have osteopenia, your fracture risk should be assessed based on the presence of the risk factors discussed previously. There are mathematical models (most notably FRAX) that make this easy. If your risk is low enough, calcium and vitamin D alone (without medications) should be enough. If your calculated risk is high, the use of medications along with calcium and vitamin D significantly reduces fracture risk. Nearly all people with osteoporosis should strongly consider medication treatment.
The currently available medications include:
- Fosamax (alendronate)
- Actonel (risedronate)
- Forteo (teriparatide)
- Reclast (zolendronic acid)
- Prolia (denosumab)
- Boniva (ibandronate)
- Evista (roloxifene)
- Estrogen Replacement Therapy
Of these listed options, I do not recommend Boniva or Evista as their benefits are too low to justify use. Estrogen, while very effective, is used in limited circumstances due to increased risk of strokes, heart attacks, and breast cancer in certain people. Forteo is used less than others as new therapy (specifically Prolia) has stepped up as a more viable option. Thus, this discussion will be limited to the remaining therapies.
Typically, when used in conjunction with calcium and vitamin D, these agents reduce the risk of future fractures by as much as 50-80% within the first one to three years of use.
Fosamax or Actonel are generally considered first line options. They are oral medications and have been on the market the longest. Thus, they are the best cost value of all medications I use. They are dosed either once weekly or once monthly. A small portion of people will stop therapy due to upset stomach or joint pain. While the optimal length of treatment has not been determined, the current evidence recommends 5-10 years of treatment.
Reclast works in a fashion similar to Fosamax and Actonel. However, it has two advantages:
- Reclast is administered only one time per year by vein in our office or other medical setting.
- Because it is administered by vein, it is ideal for folks who might experience upset stomach related to Fosamax or Actonel (again, these are rare issues).
Reclast is more expensive than the aforementioned treatments but remains very cost effective given the number of fractures it prevents.
Finally, the newest agent available at this time is Prolia. Prolia is unique is 3 ways:
- It is administered as a subcutaneous injection (similar to a vaccination) every 6 months in the physician’s office.
- It is the only agent that can be safely given to people with severe kidney disease.
- It works more quickly that other agents in building bone mass. Thus, it is ideal for people who are at the highest risk of fracturing.
Like all medications, osteoporosis drugs have side-effect risks. Some of these risks have been publicized heavily and have raised significant concern among users and potential users.
Thankfully, these risks are rare and are well known. Thus, we can discuss openly the benefits of these medications compared to their risks. As with all medications used for serious medical problems, we always want to demonstrate high likelihood of benefit compared to a much lower risk. Thankfully, when properly chosen, these medications pass that test in the vast majority.
Perhaps the two most significant of these risks is that of so-called Osteonecrosis of the Jaw (ONJ- More specifically, “bone death” in the jaw) and “atypical hip fractures.”
ONJ was first described about 15 years ago in a unique population of patients:
- People undergoing chemotherapy for cancer treatment.
- The same people receiving high dose IV reclast (monthly rather than yearly-as is often done to help with bone metastases).
- The same people then requiring tooth extraction.
When this was first noted, the medical community took strong interest in assessing this risk and association. Many new cases were noted now that the association was realized. Thankfully, we have come to know that for the average person using osteoporosis medication this risk is profoundly lower compared to this original high-risk group, perhaps 1 per 100, 000 to 1 per 1,000,000 in long-term users.
With respect to atypical hip fractures, research has shown that while these are likely related to long-termuse of Fosamax/Actonel (greater than 10 years) or Reclast (greater than 6 years) the same type of fracture is more likely in untreated osteoporosis. Thus, it still appears to provide more good than bad. We also now are limiting long-term use of these medications to optimize benefit and minimize risk. Thus, it is common to stop effective osteoporosis therapy after 5-10 years depending on the drug and the patient’s risks.
Researchers are always looking for ways to make the concept of risk more understandable. I like this example; for every person using osteoporosis therapy that has a side effect, more than 700 people don’t fracture as a result of the same treatment. Those are pretty good odds considering the severity and frequency of osteoporosis fractures.