How do Most Osteoporosis Medications work?

With the exception of teriparatide, osteoporosis medications slow bone breakdown. Healthy bones continuously break down and rebuild.

As you age — especially after menopause — bones break down faster. Because bone rebuilding cannot keep pace, bones deteriorate and become weaker.

Osteoporosis medications basically put a brake on the process. These drugs effectively maintain bone density and decrease the risk of breaking a bone as a result of osteoporosis.

Drugs in the bisphosphonate class are more alike than they are different. They all help maintain bone density. And, all bisphosphonates have been shown to reduce the chance of a fracture.

The decision to take one drug over another often is based on:

·         Preference

·         Convenience

·         Adherence to the dosing schedule

·         Cost, including whether or not the drug is a "preferred" option on your insurance company's list of acceptable medications (formulary)

Your doctor might recommend a monthly dose of medication if it's going to be better tolerated or better accepted. But if you're likely to forget to take your medicine on a monthly schedule, you might do better taking medication once a week.

Drugs such as denosumab, teriparatide and abaloparatide can be used by anyone with osteoporosis, but are more likely to be recommended for people with unique circumstances, including severe osteoporosis with very low bone density, multiple fractures, steroid use and young age.

These drugs, which are injected, might also be given to people who can't tolerate an oral bisphosphonate. Intravenous (IV) forms of zoledronic acid and ibandronate also can be an option for people who can't tolerate an oral bisphosphonate.

Bisphosphonate pills aren't absorbed well in the stomach. The main side effects of bisphosphonate pills are stomach upset and heartburn. Generic forms of these drugs may be more likely to cause these side effects.

To ease these potential side effects, take the medication with a tall glass of water on an empty stomach. Don't lie down or bend over or eat for 30 to 60 minutes to avoid the medicine washing back up into the esophagus. When the recommended wait time is over, eat to neutralize the remaining medication.

Most people who follow these tips don't have these side effects. But it's possible to take the medicine correctly and still have stomach upset or heartburn.

Infused forms of bisphosphonates don't cause stomach upset. And it may be easier for some women to schedule a quarterly or yearly infusion than to remember to take a weekly or monthly pill.

But, these drugs can cause mild flu-like symptoms in some people. You can lessen the effect by taking acetaminophen (Tylenol, others) before and after the infusion.

Two infusion medications — those that are injected directly into your vein — have been approved for osteoporosis treatment:

·         Ibandronate (Boniva), infused once every three months

·         Zoledronic acid (Reclast), infused once a year

Long-term bisphosphonate therapy has been linked to a rare problem in which the upper thighbone cracks and may break. This injury, known as atypical femoral fracture, can cause pain in the thigh or groin that begins subtly and may gradually worsen.

Bisphosphonates can also cause osteonecrosis of the jaw, a rare condition in which a section of jawbone is slow to heal or fails to heal, typically after a tooth is pulled. This occurs more commonly in people with cancer that involves the bone — who take much larger doses of a bisphonate than typically are used for osteoporosis.

There's some uncertainty about how long to take bisphosphonates because of a lack of long-term studies. Bisphosphonates have been shown to be safe and effective for up to 10 years of treatment, depending on the medication.

However, even if you stop taking the medication, its positive effects can persist. That's because after taking a bisphosphonate for a period of time, the medicine remains in your bone.

Because of this lingering effect, most experts believe it's reasonable for people who are doing well during 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 very high risk of fractures or you have very low hipbone density, taking a break from your osteoporosis medication may not be a good idea.

Osteoporosis medications lower the chance of fracture, but they don't eliminate all risk of breaking a bone. If you have a fracture while on treatment, your doctor will reassess you to check for other problems that may have contributed to the broken bone.

Depending on the outcome of that assessment, you may be a candidate to switch to a more aggressive bone-building therapy such as teriparatide. Another option might be to switch to a newer type of osteoporosis drug called denosumab.

However…

A paradox is that some medical treatments like alendronate increases bone density, but does not decrease fracture risk.