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decision pointShould I take bisphosphonate medications for osteoporosis?

Bisphosphonate medicines, such as risedronate (Actonel), ibandronate (Boniva), or alendronate (Fosamax), are the most commonly prescribed medicines for osteoporosis. Risedronate and alendronate are taken by mouth. Ibandronate is usually taken by mouth, but is also available by intravenous injection. An intravenous bisphosphonate called zoledronic acid (Reclast) is also available. But bisphosphonate medicines may not be right for you. See the Medications section of the topic Osteoporosis if you are considering taking other medicines.

Bisphosphonate medicines increase bone density and decrease your risk of spine and hip fractures. But they have some side effects, and their long-term risks have not been studied. Consider the following when making your decision:

  • You may want to take a bisphosphonate to prevent fractures if you have been diagnosed with osteoporosis.
  • You may want to take a bisphosphonate if you have osteopenia and have a strong risk factor, such as long-term corticosteroid use, a history of smoking, or other risk factors.
  • If you have osteopenia but no other risk factors for osteoporosis, you may want to try healthy habits, including taking recommended amounts of calcium and vitamin D, getting regular exercise, limiting alcohol use, and abstaining from smoking.
  • You may want to take a bisphosphonate for osteoporosis instead of hormone replacement therapy (HRT) if you are concerned about the health risks of taking HRT.
  • If you quit HRT, you may want to take a bisphosphonate to protect against the rapid bone loss that may develop after quitting HRT.
  • Your doctor may initially recommend a bisphosphonate for osteoporosis after considering your age, other existing health conditions, or other factors.
  • If you start bisphosphonates and experience bothersome side effects, other medicines for osteoporosis are available.

What is osteoporosis?

Osteoporosis is a progressive disease that causes your bones to become thin and brittle, significantly increasing your risk for fractures of the vertebrae and hip. These fractures may require hospitalization, can cause loss of height and severe back pain, and may lead to permanent disability.

What are bisphosphonate medicines?

Bisphosphonates, such as alendronate (Fosamax), slow the rate at which bone dissolves and is absorbed into the body, resulting in increased bone density and strength.

Studies show that bisphosphonates decrease the risk of fractures, including fractures of the vertebrae and the hip, by as much as 50%.1 And one study showed a 70% decrease in vertebral fractures in people taking zoledronic acid.2

Bisphosphonates are the most commonly prescribed medicines for osteoporosis. But bisphosphonate medicines may not be right for you. Depending upon your medical history and current condition, your health professional may recommend other osteoporosis medicines, such as:

  • Raloxifene (Evista).
  • Calcitonin (Calcimar or Miacalcin).
  • Teriparatide (Forteo).
  • Hormone replacement therapy (HRT) or estrogen replacement therapy (ERT).

While bisphosphonates can be taken instead of hormone replacement therapy for osteoporosis in postmenopausal women, bisphosphonates will not help hot flashes or other symptoms of menopause.

How are bisphosphonates taken?

Most bisphosphonates are taken by mouth on a daily, weekly, or monthly basis. You should take this medicine with a full glass of water in the morning on an empty stomach. Stay upright and wait 30 minutes before eating or drinking anything or taking another medicine.

Zoledronic acid and one form of ibandronate are given intravenously. Most people using zoledronic acid are given just one intravenous infusion each year. In most cases, ibandronate is given every 3 months.

If you are taking medicines for osteoporosis, you should also be taking calcium and vitamin D supplements. You should take calcium and vitamin D at least 2 hours before or after taking bisphosphonates.

What are the side effects of taking bisphosphonate medicines?

If the medicine is taken as directed, side effects are uncommon but they may include headache, pain in your muscles and joints, constipation, diarrhea, and increased gas. If you take the medicine by mouth, side effects can also include heartburn, abdominal pain, irritation of the esophagus, and difficulty swallowing. It may take several months for heartburn to appear. Allergic reactions are rare.

Serious problems with bone healing, particularly after dental surgery, have been found in some people taking bisphosphonates.3 Talk with your doctor if you are taking bisphosphonates or are about to start taking them, and need dental surgery.

Because these are relatively new medicines, their long-term effectiveness has not been studied. Most experts recommend that you have a bone mineral density (BMD) test after taking bisphosphonates for 2 years.4 But getting regular bone mineral density tests will not make bisphosphonates work better.5

Bisphosphonates should not be taken by people who have severe kidney problems. Oral bisphosphonates should not be taken by people who have heartburn or esophagitis. Bisphosphonates should not be taken with teriparatide, as neither medicine is as effective when taken together. But bisphosphonates may be taken together with HRT because the effect of these two medicines taken together is more than either alone.

If you need more information, see the topic Osteoporosis.

Your choices are:

  • Take bisphosphonate medicines as well as calcium and vitamin D supplements. Calcium and vitamin D should be taken at least 2 hours before or after taking bisphosphonates.
  • Take other osteoporosis medicines, such as raloxifene (Evista), calcitonin (Calcimar or Miacalcin), teriparatide (Forteo), and hormone replacement therapy (HRT), as well as calcium and vitamin D supplements.
  • Try healthy habits, including taking recommended amounts of calcium and vitamin D, getting regular exercise, limiting alcohol use, and abstaining from smoking.

The decision about whether to take bisphosphonate medicines takes into account your personal feelings and the medical facts.

Deciding about bisphosphonate medicines
Reasons to take bisphosphonate medicines Reasons not to take bisphosphonate medicines
  • In general, bisphosphonates decrease the risk of fractures of the vertebrae, hip, and other bones.1
  • Bisphosphonates can protect against rapid bone loss after quitting HRT.6
  • Bisphosphonate pills have schedules ranging from once a day to once a month. They have few side effects if taken as directed.
  • Zoledronic acid and a form of ibandronate can be taken by intravenous injection. The usual doses are once a year for zoledronic acid and every 3 months for ibandronate.

Are there other reasons you might want to take bisphosphonate medicines?

  • Long-term effects are not known.
  • You already have a problem with heartburn or abdominal pain, which may be made worse by oral bisphosphonates.
  • You have severe kidney problems, heartburn, or esophagitis.
  • It would be difficult for you to take this medicine as directed.
  • You are at high risk for breast cancer. You may want to talk with your doctor about taking raloxifene instead of a bisphosphonate to lower your cancer risk.
  • You are planning to have dental surgery.

Are there other reasons you might not want to take bisphosphonate medicines?

These personal stories may help you make your decision.

Use this worksheet to help you make your decision. After completing it, you should have a better idea of how you feel about taking bisphosphonate medicines. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

My doctor says I have abnormal bone loss for my age. Yes No Unsure
My doctor says I should quit taking hormones, but I'm concerned about osteoporosis. Yes No Unsure
I have severe hot flashes, so I need to take hormones anyway. Yes No NA*
I have broken a bone in the past 5 years. Yes No NA
My doctor says I have normal bone loss for my age. Yes No Unsure
I have taken corticosteroids for many years. Yes No NA
I am taking calcium supplements and have big bones. I'm not concerned about osteoporosis. Yes No NA

*NA = Not applicable

Use the following space to list any other important concerns you have about this decision.

 

 

 

 

 

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to use or not use bisphosphonate medicines.

Check the box below that represents your overall impression about your decision.

Leaning toward taking bisphosphonate medicines

 

Leaning toward NOT taking bisphosphonate medicines

         

Citations

  1. Hochberg MC (2002). Bisphosphonates. In SR Cummings et al., eds., Osteoporosis: An Evidence-Based Guide to Prevention and Management, pp. 181–195. Philadelphia: American College of Physicians–American Society of Internal Medicine.

  2. Black DM, et al. (2007). Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. New England Journal of Medicine, 356(18): 1809–1822.

  3. Woo S-B, et al. (2006). Systematic review: Bisphosphonates and osteonecrosis of the jaw. Annals of Internal Medicine, 144(10): 753–761.

  4. National Osteoporosis Foundation (2008). Clinician's Guide to Prevention and Treatment of Osteoporosis. Available online: http://www.nof.org/professionals/Clinicians_Guide.htm.

  5. Nelson HD, et al. (2001). Osteoporosis in Postmenopausal Women: Diagnosis and Monitoring. Evidence Report/Technology Assessment No. 28 (AHRQ Publication No. 01-E032). Rockville, MD: Agency for Healthcare Research and Quality.

  6. Cosman F, et al. (2002). Selection of medications and guidelines for fracture prevention. In SR Cummings et al., eds., Osteoporosis: An Evidence-Based Guide to Prevention and Management, pp. 273–281. Philadelphia: American College of Physicians–American Society of Internal Medicine.

Author Shannon Erstad, MBA/MPH
Editor Kathleen M. Ariss, MS
Associate Editor Pat Truman, MATC
Primary Medical Reviewer Anne C. Poinier, MD - Internal Medicine
Specialist Medical Reviewer Kirtly Jones, MD - Obstetrics and Gynecology
Last Updated November 21, 2008

WebMD Medical Reference from Healthwise

Last Updated: November 21, 2008
This information is not intended to replace the advice of a doctor. Healthwise disclaims any liability for the decisions you make based on this information.

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