When it's time to choose an osteoporosis medicine, you have lots of options. In the past 10 years, science has come a long way in helping women treat their bone problems.
First step: Make sure you're getting adequate calcium and vitamin D, advises Eve Scopelitis, MD, an internist with Ochsner Medical Center in New Orleans. "Vitamin D is now being recognized as a key player in osteoporosis. Even though patients are taking calcium plus D, they may not be getting enough D. They may need prescription vitamin D -- it's that important.
In fact, even when you start taking osteoporosis medicine, it's critical to keep getting these supplements, says Holly Thacker, MD, director of the Women's Health Center at The Cleveland Clinic. "A postmenopausal woman needs 1,500 milligrams calcium daily, plus 1,000 units of vitamin D. Some need prescription-strength vitamin D [Calcitriol]. This deficiency is a serious problem."
Second step: Talk to your doctor about getting a bone resorption marker test -- a blood or urine test, advises Mary Ruppe, MD, an endocrinologist with the University of Texas Health Science Center in Houston.
Bone resportion is bone loss -- and the test will tell you whether your osteoporosis medicine is having an effect on bone loss, she explains. "The first test is your baseline. Get it before you start the medication. Then get it checked after you've taken the drug for a few months to see the change." Insurance typically covers two tests the first year.
Now let's weigh the advantages and disadvantages of six main types of osteoporosis medicine.
No. 1: Bisphosphonates: Fosamax, Actonel, Boniva, Zoledronic Acid (Reclast or Zometa)
Bisphosphonates are the mainstays of osteoporosis medicines today. "They're the workhorses of osteoporosis treatment," says Bobo Tanner, MD, director of the Osteoporosis Clinic at Vanderbilt University in Nashville, Tenn. "They offer an enormous number of options for patients."
Fosomax was the first FDA-approved osteoporosis medicine 10 years ago, followed by Actonel three years later. Boniva, and Reclast are the most recent FDA approvals.
What They Do: All these drugs have been shown to increase bone density -- and Fosamax and Actonel lower the risk of spine and hips fractures. Actonel has been shown to work quickly, reducing fracture risk within the first six months, Thacker reports.
"Boniva has not yet been shown to reduce hip fractures, and that's a concern," she adds.
Reclast or Zometa increase bone mineral density and have been shown to reduce spine fractures and hip fractures -- with the reduced spine fracture risk sustained over three years. According to the manufacturer, Reclast also reduces fractures of the wrist, arm, leg, and rib. Reclast has been shown to reduce mortality in people who have already had hip fractures, Thacker tells WebMD.
The Dosing Options: There's lots of flexibility in taking bisphosphonates -- depending on whether you want to take osteoporosis medicine daily, weekly, monthly -- or get a once-a-year intravenous (IV)treatment in your doctor's office.
- Fosamax can be taken daily or weekly in pill form.
- Liquid Fosamax can be taken weekly.
- Actonel can be taken daily, weekly, or monthly.
- Boniva can be taken once a day or monthly in pill form.
- An intravenous (IV) form of Boniva can be given once yearly.
- Reclast or Zometa is a once-yearly IV infusion treatment.
An IV infusion involves a needle in your arm and a drip bag -- just like you get in a hospital. While it may sound like a slightly extreme way to get a medication, it has its advantages. "The IV drug goes directly to the bone, bypassing the GI tract entirely," Scopelitis says.
The procedure itself takes about five minutes for Boniva and 15 minutes for Reclast -- and you're done for the year. "It can be a practical option for some patients," Tanner says.
The Pill Regimen: Taking osteoporosis medicine in pill form is serious business. You don't just pop the pill. You must follow specific guidelines.
- The drugs must be taken first thing in the morning -- on an empty stomach.
- You cannot sit or lie down after taking it.
- You cannot eat or drink anything.
- You must wait for 30 to 60 minutes for the body to absorb the medicine.
- When that time period is over, you can take other medications.
The longer you wait before putting something in your stomach, the better chance the osteoporosis medicine will be absorbed. "Your stomach has to be empty," says Scopelitis. "You have to make sure there is no competition in the GI tract for the drug." You can take other medications later that morning -- but not before taking the osteoporosis medicine.
This intense regimen is important, explains Thacker, because very little of the drug is actually absorbed by the body. The body absorbs only about 1% of the drug -- "so you have to make sure you get the most from every dose," she says.
Weighing the Options: When deciding about bisphosphonates, ask yourself these eight questions:
- How frequently do you want to take an osteoporosis medicine?
- Will you really remember to take it?
- Will you follow the morning regimen for taking the pills?
- Are you taking other medications regularly?
- Do you have any GI problems?
- Do you have difficulty swallowing?
- Would you rather have a once-yearly treatment?
- What osteoporosis medicine does your insurance cover?
Pill-form bisphosphonates are not advised for people with GI problems like gastritis or ulcers -- or for people with serious esophageal problems like stricture. "We want to make sure patients absorb the drug," says Thacker. "If they have those conditions, they really need to consider an IV."
Also, for patients who don't have a pharmacy benefits plan -- with their insurance or with Medicare -- intravenous Reclast or Boniva may be the better option, says Tanner. "Because it's done at the physician's office, it will be covered." However, you must meet your insurance deductible and co-pay.
Generic Fosamax: If you are a good candidate for pill form, Fosamax is now available in a cheaper, generic form. It's a good option if finances are a problem, Tanner says. "Some people can't afford more than $4 a month." It's important to know, however, that generics are required to be 80% equivalent to the brand medicine, and may not be 100% identical, she tells WebMD. "For a medication that is so difficult for the body to absorb, I think that's a risk."
Possible side effects: These osteoporosis medicines can upset the stomach, causing heartburn for a day or two. "Actonel seems to cause a bit less GI side effects," says Ruppe.
However, the side effects are the main reason people quit their osteoporosis medicine, Ruppe tells WebMD. That's when the bone resorption marker test can help. "It can show the effect of medication, whether it's working. Somebody who needs reassurance needs this. It's positive reinforcement to keep taking the medication."
Because Reclast is given once-yearly in treating osteoporosis, some patients are nervous about side effects -- whether they will last a whole year, says Tanner. "About 20% get a flu-like illness the first few days afterwards. A very rare event is bone pain that may go on for awhile. But less than 1% get that. It's pretty rare." Treatment with ibuprofen (such as Advil, Motrin) or acetaminophen (such as Tylenol) helps improve the symptoms.
Considering the risks: Atrial fibrillation (abnormal heart rhythms) has been a concern. A large study showed that some patients treated with Zoledronic acid (Reclast or Zometa)had more abnormal heart rhythms than those treated with placebo. Other follow-up studies did not show this effect. The FDA has advised that patients should not stop taking bisphosphonates -- but to report side effects and symptoms to their doctors.
There is also slight risk of osteonecrosis of the jaw, which can cause pain, swelling, exposed bone, local infection, and fracture of the jaw. But osteonecrosis is rare and has been seen in patients who have had chemotherapy or radiation therapy and are receiving long-term bisphosphonate therapy, says Tanner. "It's extremely rare," he tells WebMD. "The benefit of preventing bone fractures far outweighs the risk of osteonecrosis of the jaw."
Thacker agrees: "The risk of osteonecrosis of the jaw is overexaggerated. The Horizon Trial studied Reclast in 8,000 postmenopausal women and found no increase in osteonecrosis of the jaw."
No. 2: Evista: Breast Cancer and Osteoporosis Prevention
For women with osteopenia [low bone density but not yet osteoporosis] -- or who have difficult GI problems taking bisphosphonates -- Evista is an option. Evista is a selective estrogen receptor modulator, or SERM, used to treat breast cancer. It is also approved by the FDA to prevent and treat osteoporosis.
The drug binds with estrogen receptors throughout the body to produce some estrogen-like effects -- including prevention of bone loss.
Evista helps prevent spine fracture, not hip fracture, reports Thacker. "Evista is not as potent as estrogen therapy or bisphosphonates on bone. But the FDA has approved it for osteoporosis, and to reduce risk of breast cancer. Women can get those extra benefits from Evista."
Possible side effects: Though rare, there is risk of deep vein thrombosis.
No. 3: Forteo: The Bone Builder
If you are treating severe osteoporosis, you likely need a medicine called Forteo. Forteo is a parathyroid hormone that increases bone density and bone strength to prevent fractures. Forteo stimulates bone-forming cells called osteoblasts to build bone. This osteoporosis medicine has a dramatic effect on bone density in the spine and reduces fracture by up to 90%.
Forteo is given daily day for a period of time, and must be injected. This osteoporosis medicine is generally prescribed for people with severe osteoporosis, or who have already had one or more fractures. You can inject it yourself at home, or have someone else do it.
"Forteo builds up bone, whereas the other drugs keep bone from breaking," explains Scopelitis. "Women who have very severe osteoporosis will skip the other drugs and go for Forteo, which is stronger."
No. 4: Denosumab: In the Pipeline
Like Forteo, this osteoporosis treatment also builds bone. Phase 3 trials showed a decreased rate of vertebral and hip fractures. The drug activates bone-building osteoblasts by a different mechanism than Forteo does. This new osteoporosis drug is injected, but women may need injections just a few times a year. The drug is due for a 2009 launch, reports Ruppe.
"The preliminary information on denosumab looks good," Tanner tells WebMD. "People who haven't tolerated or benefited from other drugs may find it useful."
No. 5: Calcitonin: For Combination Therapy
Calcitonin is the oldest drug for treating osteoporosis, approved in 1984 -- and is still used occasionally. It is a hormone made from salmon calcitonin, and helps to slow bone loss, increases bone density, and may relieve bone pain. It works by binding with damaging cells called osteoclasts, preventing bone loss. Calcitonin's key benefit is reducing risk of spinal fractures.
Calcitonin is often used as an additional osteoporosis medicine or when someone cannot tolerate a bisphosphonate. It may be given as an injection.
Possible side effects: Diarrhea, flushing of face or hands, increased urination, loss of appetite.
No. 6: Estrogen Hormone Therapy: Prevent Hot Flashes and Osteoporosis
For women who want to get rid of hot flashes -- and prevent osteoporosis -- hormone replacement therapy (HRT) is an option. However, there are serious risks of heart disease, stroke, and blood clots in the lungs. There also are increased risk of breast cancer and possibly other cancers.
Those risks end when women stop taking HRT, new research shows. But doctors prescribe the lowest possible dose of HRT for the shortest amount of time for women who have bothersome hot flashes. The bone-building benefits of HRT are a plus -- as it is known to preserve bone and prevent fractures.
Tanner doesn't support the use of HRT for osteoporosis. "HRT was pretty much shot down by the FDA -- relegated to short-term use only," Tanner tells WebMD. "The other issue is that HRT has no lasting value. As soon as you stop taking it, you go through bone menopause, unlike the bisphosphonates, which provide sustained benefit for months if not years if you stop taking it." Fosamax stays in the bone for 10 years, he adds.
But Thacker believes that "hormonal therapy is greatly overlooked." She is author of the book, Women's Health: Your Body, Your Hormones, Your Choices. "It can reduce all types of fractures in women. If you're a mid-life woman at risk for osteoporosis, with hot flashes and other menopausal symptoms, hormone therapy is a good idea. If you're under age 60, the benefits outweigh the risks."