Osteoporosis is a disease that causes bones to lose mass, to deteriorate, and to become brittle. This means that bones also lose their strength, which increases the chance of breaks or fractures. Fractures caused by osteoporosis can be debilitating and reduce quality of life. They can result in pain, emotional distress, and loss of independence. For more information about osteoporosis, please see the Osteoporosis Overview.

While men can develop osteoporosis, 80 percent of osteoporosis patients in the United States are women. According to the National Institutes of Health, 10 million people already have the disease (2 million are men), and 34 million more have low bone mass, which is a major risk factor for osteoporosis. Although osteoporosis can strike at any age, it most often appears after menopause when women’s hormone levels decline. At least 1.5 million fractures occur each year because of osteoporosis, costing more than $14 billion. The most typical sites of fractures related to osteoporosis are the hip, spine, wrist, and ribs, although the disease can affect any bone in the body. 

Treatment Options

A complete osteoporosis treatment program includes focusing on proper nutrition, exercise, and safety issues to prevent falls that may result in fractures. In addition, your doctor may prescribe medications to slow or stop bone loss, increase bone strength, and reduce fracture risk.

Osteoporosis medications affect the bone remodeling cycle. Bone remodeling is made up of two stages: bone resorption (bone loss) and bone formation. These stages usually occur together to maintain a healthy bone. In osteoporosis, the cycle becomes imbalanced and bone loss occurs more rapidly than bone formation, resulting in a weakened bone. 

Anti-Resorptive Medications

Bisphosphonates are nonhormonal agents that bind to active sites of bone remodeling and inhibit the action of osteoclasts, thereby preventing bone resorption. Bisphosphonates reduce bone loss, increase bone density, and prevent fractures of the hip and spine.

Oral bisphosphonates, alendronate (Fosamax®), ibandronate (Boniva®), and risedronate (Actonel®), are poorly absorbed and can cause indigestion, nausea, and esophageal irritation. For this reason, they must be taken on an empty stomach first thing in the morning, with a full glass of water (6-8 ounces), and the patient must remain upright (standing or sitting) for 30 to 60 minutes after taking a dose.

Because this procedure can be inconvenient, alendronate and risidronate are available in a once-weekly tablet and ibandronate is available in a once-monthly tablet. Other less common side effects of the oral bisphosphonates include bone, joint, and muscle pain. Bisphosphonates can be safely taken for 5-10 years.

Recently, Warner Chilcott has released a delayed-release Risedronate tablet that can be taken immediately after eating, eliminating the 30 to 60 minute delay mentioned above.

Intravenous formulations of the bisphosphonates are available for patients who cannot remain upright for the required length of time and for those who cannot tolerate the GI side effects of the oral agents. Ibandronate IV is given every three months and zolendronic acid is available in a once-yearly formulation. Side effects that can occur after IV bisphosphonates include flu-like symptoms, fever, pain in muscles and joints, and headache. In 2008, generic alendronate became available for about one-tenth of the cost of the brand name bisphosphonates.

 

Drug	Brand Name / Dose	Side Effects
Alendronate	Fosamax (generic available) – Prevention: 35mg/week – Treatment: 70mg/week Fosamax Plus D 70 mg + 2800 IU Vitamin D3/week Fosamax Oral Liquid 70 mg/week	Nausea and vomiting Heartburn Irritation or pain of the esophagus Difficulty swallowing Constipation or diarrhea Gas
Risedronate	Actonel 150 mg/month 75 mg twice monthly 35 mg/week Actonel with calcium 35 mg/week + calcium 500 mg/day Atelvia delayed release tablet 35 mg/week	Nausea and vomiting Heartburn Irritation or pain of the esophagus Difficulty swallowing Constipation or diarrhea Gas
Ibandronate	Boniva tablet 150 mg/month Boniva injection 3 mg IV every 3 months	Nausea and vomiting Heartburn Irritation or pain of the esophagus Difficulty swallowing Constipation or diarrhea Gas
Zolendronic acid	Reclast 5 mg IV yearly	Nausea and vomiting Heartburn Irritation or pain of the esophagus Difficulty swallowing Constipation or diarrhea Gas

Calcitonin

Calcitonin is a naturally occurring hormone that slows bone loss and increases bone density in the spine. It can be used to treat osteoporosis in women who are at least five years beyond menopause. Because calcitonin is not absorbed orally, a nasal spray containing salmon calcitonin has been developed to treat osteoporosis. It is easy to deliver and has few side effects. Calcitonin is also available as a subcutaneous injection, although this is not often used for osteoporosis.

 

Drug	Brand name	Dose	Side effects	How to use
Calcitonin nasal spray	Fortical Nasal Spray Miacalcin Nasal Spray Generic available	200 IU daily	Rhinitis Nasal irritation Flushing of the face and hands Nausea, vomiting, diarrhea	One spray alternating nostrils daily

 

Estrogen

Estrogen Therapy (ET) (for women who have had a hysterectomy) and Hormone Therapy (HT) (estrogen + progesterone for women with an intact uterus) are approved for prevention of osteoporosis in postmenopausal women.

ET and HT should be used in women who are recently postmenopausal and have symptoms of menopause such as hot flashes and vaginal dryness. ET and HT prevent bone resorption and prevent fractures of the spine and hip as well as other fractures. ET and HT are available in many different doses and dosage forms such as transdermal patches and vaginal rings. Even low doses of ET and HT have been shown to protect bones.

Adverse effects associated with ET and HT include increased risk of blood clots, gall bladder disease, and breast cancer. ET and HT are generally prescribed for no more than five years after menopause; however, some women may benefit from longer therapy.

Oral Estrogen Therapy Products 

Oral estrogen	Brand name	Strengths (mg)	Comments	Side effects
Conjugated Equine Estrogens (CEE)	Premarin	0.3 0.45 0.625 0.9 1.25 2.5	Purified estrogens derived from pregnant mares’ urine, >11 different compounds	Spotting Headache Breast pain Abdominal pain
Micronized Estradiol	Estrace Generic: Mylan, Geneva	0.5 1.0 1.5 2.0	Same as naturally occurring estrogen pre-menopause; however, undergoes significant first pass metabolism to estrone and conjugates	Spotting Headache Breast pain Abdominal pain

Oral Hormone Therapy Combinations

 

Product/Manufacturer	Estrogen dose	Progestin dose	Comments
Premphase	Conjugated estrogens (CEE) 0.625 mg/day x 28 days	Medroxylprogesterone (MPA) 5 mg x 14 days	Cyclic regimen
Prempro Prempro 0.45 mg/ 1.5 mg Prempro 0.3 mg/ 1.5 mg	CEE 0.625 mg/day x 28 days CEE 0.45 mg CEE 0.3 mg	MPA 2.5 mg x 28 days MPA 1.5 mg MPA 1.5 mg	Continuous regimen Continuous regimen Continuous regimen
Femhrt (Parke-Davis)	Ethinyl estradiol 5 mcg	Norethindrone acetate 1 mg	Continuous therapy Blister card of 28 tablets
Ortho-Prefest (Ortho-McNeil)	Estradiol 1 mg (#15)	Estradiol 1 mg + Norgestimate 0.09 mg (#15)	3 days estradiol alternating with 3 days estradiol + norgestimate continuous
Activella (Pharmacia)	Estradiol 1 mg, 0.5 mg	Norethindrone acetate 0.5 mg, 0.1 mg	Continuous regimen, Dialpack

Transdermal Estrogen/Estrogen and Progestins

 

Drug	Brand name	Strengths	Comments
17 beta-Estradiol	Climara	0.025 mg/day 0.05 mg/day 0.075 mg/day 0.1 mg/day	Once weekly patch
17 beta-Estradiol Levonorgestrel 15 mcg/day	ClimaraPro	0.045 mg/day	Once weekly patch
17 beta-Estradiol	Alora Esclim Estraderm Vivelle Vivelle-Dot	0.025 mg/day 0.05 mg/day 0.075 mg/day 0.1 mg/day Vivelle & Esclim also available in 0.037 mg dose	Twice weekly patch Twice weekly patch Postage stamp-sized patch
Estradiol/Norethindrone	CombiPatch (2 times/week)	E 0.05 / 0.14 E 0.05 / 0.25	Continuous HRT sequential
Estradiol	Estrasorb (Novavax)	Topical emulsion (lotion)	Apply to thighs or calves
Estradiol gel	EstroGel (Solvay) Divigel 0.1%	Metered dose estradiol 0.075 mg/day Daily packet 0.025 mg, 0.05 mg, 0.1 mg	Apply to one arm daily, from wrist to shoulder Apply to thigh, do not wash for one hour

Vaginal Estrogen Ring

 

Drug	Brand name	Strengths	Comments
Estradiol acetate	Femring	0.05 mg/day 0.1 mg/day	Systemic therapy of menopausal symptoms Prevention of osteoporosis

Selective Estrogen Receptor Modulator (SERM)

Raloxifene is a selective estrogen receptor modulator (SERM) with estrogen-like effects on bone and antiestrogen effects on the uterus and breast. Raloxifene reduces bone resporption, increases bone density, and reduces the risk of spine fractures. It protects against estrogen-induced cancer of the uterus and breast. Like estrogen, raloxifene increases the risk of blood clots. It should only be used in women well past menopause because it may cause hot flashes.

Drug	Brand Name	Dose	Indication	Side Effects
Raloxifene	Evista	60 mg/day	Prevention or treatment of osteoporosis	Hot flashes Leg cramps Deep vein thrombosis (blood clots)

 

RANK-Ligand Inhibitor

In 2010 an entirely new type of anti-resorption drug was approved. Denosumab (Prolia) is a RANK-Ligand inhibitor. After menopause, decreased estrogen levels lead to increased production of RANK-ligand. RANK-Ligand is a protein that stimulates osteoclast-induced bone loss. Denosumab 60mg, a subcutaneous injection given every six months, reduces the activity of RANK-Ligand, resulting in decreased bone resorption and increased bone strength. Denosumab reduces the incidence of vertebral, nonvertebral, and hip fractures. Denosumab is indicated for post-menopausal women who have had fractures or are at high risk of fractures who have failed other osteoporosis therapy or who are intolerant of other osteoporosis therapy. Calcium and vitamin D supplements should be taken during Denosumab therapy. Side effects of Denosumab may include low calcium levels and skin rash. Denosumab can also affect the immune system. People with weakened immune systems can be at increased risk of serious infections. Patients taking denosumab should report any signs of infection to their health care provider such as fever or severe malaise.

 

Drug	Brand name	Dose	Indication	Side effects
Denosumab	Prolia	60 mg subcutaneous injection / 6 months	Indicated for post-menopausal women with increased risk of fracture who cannot take other osteoporosis medications or for whom other osteoporosis medications do not work well.	Rash Hypocalcemia Increased risk of infection

 

Anabolic Medications

Anabolic drugs are a new and distinct class of medications for osteoporosis. These drugs increase the rate of bone formation. The first drug in this category is Teriparatide (Forteo), a form of parathyroid hormone. The daily 20 mg subcutaneous dose is easily measured and administered by its unique pen device. The medication is given for a maximum of two years, which is considered the “anabolic window.”

After it is discontinued, a bisphosphonate is then prescribed to retain the benefits of treatment and prevent bone resorption. Good candidates for teriparatide are persons with very low bone density (T-scores less than -3.0) who have experienced an osteoporosis-related fracture or anyone who has had fractures occur while on anti-resorptive therapy. All anti-resorptive therapy should be discontinued before starting teriparatide.
 

 

Drug	Brand name	Dose	Indication	Side effects
Teriparatide	Forteo	20 mg subcutaneous daily	Osteoporosis with fractures	Leg cramps Dizziness

 

For more information:

Go to the Osteoporosis health topic.