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Osteoporosis treatment puts brakes on bone loss
Osteoporosis treatment may involve medication along with lifestyle change. A Mayo Clinic specialist answers some of the most common questions about osteoporosis treatment.
By Mayo Clinic staff
If you're undergoing osteoporosis treatment, you're taking a step in the right direction for your bone health. But you might find yourself facing unanswered questions about your therapy. Is the medication you're taking the best one for you? How long will you have to take it? Why does your doctor recommend that you take a weekly pill when your friend only takes a pill once a month?
Kurt Kennel, M.D., a specialist in endocrinology at Mayo Clinic in Rochester, Minn., answers these questions about osteoporosis treatment in women and describes how common osteoporosis medications work.
Which medications are most commonly used for osteoporosis treatment?
Bisphosphonates are — by far — the most common medications prescribed for osteoporosis treatment. Fosamax, Actonel and Boniva are just a few examples from this family of medications.
Hormones, such as estrogen, and some hormone-like medications approved for preventing and treating osteoporosis, such as raloxifene (Evista), also play a role in osteoporosis treatment. But fewer and fewer women are receiving these medications for osteoporosis treatment because the bisphosphonates are so effective.
Doctors, in general, feel comfortable prescribing bisphosphonates for osteoporosis treatment. Fosamax — a commonly prescribed bisphosphonate — has been on the market for about 10 years, so there's proven experience with safety. And bisphosphonates really don't affect anything but the bone. Hormones, on the other hand, raise some concerns about what effects they'll have on other parts of the body, such as the breast or circulation. With bisphosphonates, doctors have fewer concerns about side effects or medication interactions. These medications tend to be well tolerated, for the most part, by the women who take them.
How do bisphosphonates work?
Bisphosphonates slow the bone breakdown process. Healthy bones are in a state of continuous breakdown and rebuilding. As you get older, and especially after menopause when your estrogen levels decrease, the bone breakdown process accelerates. When bone rebuilding fails to keep pace, bones deteriorate and become weaker. Bisphosphonates basically put a brake on that. These drugs effectively preserve or maintain bone density during menopause — and decrease the risk of breaking a bone as a result of osteoporosis.
How do you know if you're taking the right medication?
Drugs in the bisphosphonate class are more alike than they are different. Some studies show differences in potency or effectiveness at maintaining bone density, but they're all still effective drugs. All bisphosphonates have been shown to reduce the chance of a fracture.
Commonly, the decision to take one drug over another is based upon preference, convenience and adherence to the dosing schedule. A doctor might recommend a monthly dose of medication if it's going to be better tolerated or better accepted. But if you're the type of person who might forget to take your medicine every month, you might do better taking it once a week.
Is there an advantage to an injected bisphosphonate versus a daily or monthly oral regimen?
There may be. Two infusion medications have been approved for osteoporosis treatment. Ibandronate (Boniva injection) is injected into your vein once every three months, and zoledronic acid (Reclast) is injected once a year.
Adherence to osteoporosis medication dosing schedules is an important consideration. Researchers report that most women taking an oral bisphosphonate stop treatment or take less than the fully prescribed amount of medication after one year of therapy. This reduces the effectiveness of the medication. An injection given quarterly or yearly, on the other hand, ensures that women are fully protected until their next treatment.
Reclast injection, recently approved by the Food and Drug Administration, might be slightly more effective than other osteoporosis drugs. For instance, Reclast — unlike Boniva — has been shown to reduce the risk of hip fractures.
Finally, if you're like many, you might already take several pills a day to manage other health conditions. Or you might experience unbearable stomach upset from your current oral bisphosphonate. Switching to an injection provides a welcome alternative.
How long should you take a bisphosphonate for osteoporosis treatment?
Up to five years of treatment with bisphosphonates is safe and effective. The scientific literature is full of good studies of all the bisphosphonate medications that prove their safety and show their effectiveness at preventing fractures of the hip and spine for up to five years.
Beyond five years of treatment, there's less certainty. There just haven't been many long-term studies done. One thing we know, though, is that even if you stop taking the medication, its positive effects can still persist. That's because after taking a bisphosphonate for a period of time, you build up the medicine in your bone.
Because of this lingering effect, some experts believe it's reasonable for women who are doing well on treatment — those who have not broken any bones and are maintaining bone density — to consider taking a holiday from their bisphosphonate after taking it for five years. But if you're at high risk of fractures or you have very low bone density, taking a break from your osteoporosis medication probably isn't a good idea.
How long can a holiday from osteoporosis medication be?
If you're at low risk of fractures, you could take one year or even up to five years off. A recent report in the Journal of the American Medical Association shows that women who didn't take any medication beyond five years, and who took an inactive pill (placebo) between years five and 10 instead, still experienced protective effects from the bisphosphonates. Symptomatic vertebral fractures were a little more common in women who stopped the medication, but most other vertebral fractures, as well as hip fractures and wrist fractures, were no more common in people who stopped after five years than in those who kept going from years five to 10.
If you take a holiday from your osteoporosis medication, will you need to restart treatment at some point?
If you experience a major decline in your bone density or you have a fracture, you would need to go back on therapy.
Some women approach taking a holiday from their medications by establishing a predetermined restart date with their doctors. So, for instance, you could take a break of one or two years, all the while knowing you'll restart your medicine when that period is over.
What are the side effects of bisphosphonates?
The most common side effect with any of the bisphosphonates is stomach upset or heartburn. To ease this potential side effect, take the medication on an empty stomach with a tall glass of water. And don't lie down or bend over for 30 to 60 minutes to avoid the medicine washing back up into the esophagus. The majority of women who follow these tips don't experience this side effect. But it's possible for an unlucky few who take the medicine correctly to still have stomach upset or heartburn.
There's also a theoretical concern about getting too much of a bisphosphonate in your bones, causing the bone to actually become more fragile over time. But in the longer term follow-up studies, this complication hasn't been apparent. Researchers just aren't finding that women suddenly go from having fewer and fewer fractures to having more fractures as they go beyond five years of treatment.
The bisphosphonates could potentially cause osteonecrosis of the jaw — a rare condition in which a section of jawbone dies and deteriorates. The bisphosphonates, as a family of medications, have the potential to affect the jawbone. This side effect occurs primarily in people who take very large doses of the medication by vein (intravenously) — much larger than the doses typically used for osteoporosis — because they have cancer in their bones. In these individuals, a small number have poor healing of the jawbone after a dental extraction, after trauma to the jaw or sometimes even just spontaneously.
The American Dental Association estimates that the risk of osteonecrosis of the jaw in a woman taking bisphosphonates by mouth for osteoporosis is less than one in 100,000. Before you start taking a bisphosphonate, make sure your teeth are healthy. There's no recommendation to stop the medication before having a dental procedure, but do tell your dentist you're taking a bisphosphonate and follow his or his recommendations for good oral hygiene.
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