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Photograph of osteoporatic hip with significant bone loss

Although there is no cure for osteoporosis, several medications approved by the U.S. Food and Drug Administration (FDA) can help stop or slow bone loss, or help form new bone, and reduce the risk of fractures. These medications come in a range of formulations, from daily tablets to yearly intravenous infusions.  There is no ideal medication for everyone.  Your health history and personal preferences are considerations that should be discussed with your healthcare provider when selecting a medication.

Osteoporosis medications fall into two different categories: antiresorptives and anabolics.

  • Antiresorptive medications include bisphosphonates, denosumab, calcitonin, hormone therapy, and raloxifene.  These medications work by slowing bone breakdown.
  • Anabolic medications include teriparatide, abaloparatide, and romosozumab-aqqg. These medications work by stimulating bone formation.

NOTE: Brand names included in this publication are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.

Bisphosphonates

Alendronate (Fosamax, Fosamax Plus D, and Binosto) is approved for the prevention and treatment of osteoporosis in postmenopausal women and for the treatment of osteoporosis in men. It also is approved for the treatment of glucocorticoid-induced osteoporosis in men and women.  For prevention and treatment, alendronate can be taken as either a daily or weekly tablet.

Ibandronate (Boniva) is approved for the prevention and treatment of osteoporosis in postmenopausal women.  For both prevention and treatment it is taken as a once monthly tablet.  For treatment, it is also available as an intravenous injection given every three months by a healthcare professional.

Risendronate (Actonel) is approved for the prevention and treatment of osteoporosis in postmenopausal women and for the treatment of osteoporosis in men.  It is also approved for the prevention and treatment of glucocorticoid-induced osteoporosis in men and women. For both prevention and treatment, risendronate is a tablet that can be taken daily, weekly, or monthly.

Zoledronic acid (Reclast) is approved for the prevention and treatment of osteoporosis in postmenopausal women.  It is also approved to increase bone mass in men with osteoporosis and for the prevention of new clinical fractures in patients who have recently had a low-trauma hip fracture. It is also approved for the prevention and treatment of glucocorticoid-induced osteoporosis in men and women. It is given as an intravenous infusion once-a-year for osteoporosis treatment and every two years for osteoporosis prevention.

Alendronate, risendronate, and zoledronic acid increase bone density and reduce the incidence of spine, hip, and other fractures. Ibandronate reduces the incidence of spine fractures. Most oral bisphosphonates must be taken first thing in the morning after waking up and on an empty stomach, at least 30-60 minutes before having anything to eat or drink. Patients must remain upright during this 30-60 minute period. This careful dosing is necessary to ensure that the medication is absorbed and to minimize the risk of irritation of the esophagus. Side effects for oral bisphosphonates include gastrointestinal problems such as difficulty swallowing, inflammation of the esophagus, and gastric ulcers. Side effects for intravenous bisphosphonates include flu-like symptoms, fever, pain in muscles or joints, and headache. There have also been rare reports of osteonecrosis of the jaw.

 
 
Denosumab

Denosumab (Prolia) is approved for the treatment of osteoporosis in postmenopausal women at high risk of fracture and to increase bone mass in men with osteoporosis at high risk of fracture. It is also approved to increase bone mass in men receiving androgen deprivation therapy for prostate cancer who are at high risk of fracture, to increase bone mass in women at high risk for fracture receiving aromatase inhibitor therapy for breast cancer, and for the treatment of glucocorticoid-induced osteoporosis in men and women at high risk of fracture. Denosumab increases bone density and reduces the incidence of spine, hip, and other fractures. Denosumab is an injection that is administered by a healthcare professional every six months. It may lower the calcium levels in the blood. Patients with weak immune systems may have an increased chance of having serious infections with denosumab. Even patients who have no immune system problems may be at higher risk of certain infections. Patients should contact their healthcare provider right away if signs of infection occur including fever, chills, red and swollen skin, skin that is hot or sore to the touch, severe pains in the abdomen, or pain or burning when passing urine. 

 
 
Calcitonin

Calcitonin (Fortical, Miacalcin) is a synthetic hormone for the treatment of osteoporosis in postmenopausal women who are at least five years beyond menopause when other medications are not suitable. Calcitonin slows bone breakdown and increases bone density in the spine. It reduces the risk of spine fractures, but has not been shown to decrease the risk of non-spine or hip fractures. Calcitonin is available as a daily nasal spray or a daily injection. Common side effects with nasal calcitonin are a runny nose, headache, back pain and nosebleed. Injectable calcitonin may cause an allergic reaction and unpleasant side effects including flushing of the face and hands, urinary frequency, nausea and a skin rash. Due to the possible connection between cancer and the use of calcitonin, the use of this medicine should be reviewed from time to time with your healthcare provider.

 
 
Menopausal Hormone Therapy

Menopausal hormone therapy is approved for the prevention of osteoporosis in postmenopausal women. It reduces bone loss, increases bone density in both the spine and hip, and reduces the risk of hip, spine and other fractures in postmenopausal women while also helping to relieve menopausal symptoms. It is commonly available as a tablet, skin patch, and a variety of other formulations. According to the FDA, postmenopausal women should consider other osteoporosis medications before taking menopausal hormone therapy to prevent osteoporosis. Because estrogen use has risks, women should discuss with their healthcare provider whether the benefits outweigh the risks. Women who decide to take menopausal hormone therapy should take the lowest possible dose for the shortest period of time to control menopausal symptoms and achieve desired goals.

 
 
Raloxifene

Raloxifene (Evista) is approved for the prevention and treatment of osteoporosis in postmenopausal women. It is neither an estrogen nor a hormone, but a selective estrogen receptor modulator, developed to provide the beneficial effects of estrogens without all of the potential disadvantages. Raloxifene reduces the risk of spine fractures. There is no data showing that raloxifene reduces the risk of hip and other non-spine fractures. It is approved to decrease the risk of invasive breast cancer in postmenopausal women with osteoporosis and even in women without osteoporosis who are at high risk of breast cancer. For both prevention and treatment, raloxifene is taken as a daily tablet. Side effects include hot flashes, leg cramps, increased risk of deep vein thrombosis, swelling and temporary flu-like symptoms.

 
 
Teriparatide

Teriparatide (Forteo) is a daily injection approved for the treatment of osteoporosis in postmenopausal women and in men who are at high risk for fracture. It is also approved for the treatment of osteoporosis in men and women who are at high risk for fracture as a result of long-term use of steroid medications. This medication rebuilds bone and significantly increases bone mineral density. Teriparatide reduces the risk of spine and non-spine fractures. It can be taken for a maximum of two years. Side effects can include leg cramps, nausea, and dizziness.

 
 
Abaloparatide

Abaloparatide (Tymlos) is a daily injection approved for the treatment of osteoporosis and is specifically indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture. Cumulative use of abaloparatide and parathyroid hormone analogs (e.g. teriparatide) for more than two years during a patient’s lifetime is not recommended. Adverse effects may include excess calcium in the urine, dizziness, nausea, headache, palpitations, fatigue, upper abdominal pain, and vertigo. 

 
 
Romosozumab-aqqg

Romosozumab-aqqg (Evenity) is approved for the treatment of osteoporosis in postmenopausal women at high risk for fracture. It comes as a set of two subcutaneous injections that should be administered by a healthcare provider once monthly for 12 months. Its use is limited to 12 monthly doses as the anabolic effect of romosozumab-aqqg wanes after this period of time. 

 

Revised May 2020

Source: National Osteoporosis Foundation

 
 
 
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