Andrea Singer, MD
Andrea Singer, MD, division director of Women’s Primary Care and of bone densitometry at MedStar Georgetown University Hospital in Washington, D.C. and clinical director of the National Osteoporosis Foundation.
Bottom Line: Answers to 5 key questions to help you use these drugs effectively and safely.
Drugs to treat osteoporosis work, but making them work well—and safely—is not quite as simple as popping a multi-vitamin. Here’s what you need to know to help your bones and be safe…
The answer depends on your degree of fracture risk and the goals of your treatment, such as building bone, preventing breaks by slowing bone loss or both.
People in earlier stages of osteoporosis are often prescribed one of the oral medications known as antiresorptives. These drugs, such as the bisphosphonates alendronate (Fosamax), risedronate (Actonel, Atelvia) and ibandronate (Boniva), slow the rate of bone loss.
In contrast, the most effective treatments for people at the highest risk for fractures, which includes people who’ve already had fractures or have severe osteoporosis, are the bone-building anabolic drugs teriparatide (Forteo) and abaloparatide (Tymlos) as well as two other antiresorptives, the bisphosphonate zoledronic acid (Reclast), which is given by IV, and the injectible non-bisphosphonate denosumab (Prolia).
Some patients end up trying more than one drug as they and their doctors search for the most effective for them. In these cases, the sequence in which a patient takes different osteoporosis medications matters. Example: The bone-building anabolics work best when given first—meaning, no prior treatment with a bisphosphonate.
No—in fact, some should not be taken indefinitely to protect against rare, but serious potential side effects. For example, oral bisphosphonates are generally taken for five years, IV bisphosphonates, for three. Denosumab can be taken safely for up to 10 years and then must be followed by another antiresorptive to preserve its effects and avoid an increase in the risk for fracture. Teriparatide and abaloparatide are taken for only two years, after which you need to switch to another medication to preserve the bone building benefits.
If medications are stopped, treatment may be restarted if your bone density goes down again—for example, your doctor may suggest you repeat the course of a bisphosphonate. This decision will likely be based on whether your risk for a fracture outweighs any increased risk for side effects.
If you don’t have any fractures after, say, five years on an oral bisphosphonate, your doctor might suggest a “drug holiday” with clinical and bone density monitoring. Drug holidays are possible only with this class of drugs because they have long half-lives, meaning they stay in the bone and continue to work even after you have stopped taking them. Your time off from the drug could be quite long—for example, after perhaps two or three years off the medication, you and your doctor will likely review your condition and see whether your fracture risk is stable or has increased and whether the drug should be started again.
In contrast to bisphosphonates, the anabolic medications and denosumab have short half-lives. That’s why when you stop taking them, you lose the benefits if no other medication follows, so you’ll likely need a next step in treatment, often a bisphosphonate.
As part of your treatment for osteoporosis, whatever drug you may be taking, it’s important that you get enough calcium and vitamin D. (It’s also important not to get too much calcium, however, especially if you are taking an anabolic drug that adds to the calcium levels in your body. Discuss the right amount for you with your doctor.)
According to a study published in Bone Research, taking supplements of calcium and vitamin D with denosumab made the drug even more effective than would be expected without the supplements.
Generally, women up to age 50 and men up to age 70 need 1,000 mg of calcium daily. After these ages, most men and women need 1,200 mg daily. It’s best to get calcium from your diet if you can, but if you have to add a supplement, that’s okay. There are different types of calcium formulas, such as calcium carbonate and calcium citrate. The most important factor is how much elemental calcium is in the product you choose—that’s the net amount of the mineral in the product. Tip: Add nonfat powdered milk to almost any recipe, and you’ll be adding 50 mg of calcium per tablespoon.
Both men and women under age 50 need 400 international units (IU) to 800 IU of vitamin D daily. Men and women over 50 need 800 IU to 1,000 IU of vitamin D. A safe daily upper limit for most adults is 4,000 IU. Vitamin D is available through three main sources— sunlight, food and supplements. Very few foods naturally contain vitamin D, but fatty fish such as mackerel, salmon and tuna do. Vitamin D is also added to many packaged foods, of course. Even so, most people need to supplement to get enough vitamin D. There are two types of supplements, D2 (ergocalciferol) and D3 (cholecalciferol). Studies show that D3 is the more effective of the two.
Don’t try to assess your need for supplemental calcium or vitamin D yourself—you might wildly under- or over-estimate your need. Ask your doctor to help you evaluate this!
Also ask about vitamin K. It helps bones absorb calcium. Aim for 90 micrograms (mcg) a day—the amount in one cup of broccoli. Leafy greens are great sources and range from from 75 mcg (spinach) to 225 mcg (kale) in just a half-cup. If you take a blood-thining drug such as warfarin, ask your doctor if you can safely add vitamin K-rich foods to your diet if you aren’t already eating them—because vitamin K acts as a blood clotter and could interfere with the effectiveness of that medication.
Make a point of getting at least 30 minutes a day of weight bearing exercise, which strengthens your bones. You’ll also improve balance, which reduces the risk for falling. However, speak with your doctor before starting any exercise so that a safe program can be designed for you, one that takes into account the current health of your bones and your fracture risk.
Also very important: Reduce your chance of fracture by even further reducing your chance of falling. A gait assessment, done by your doctor or a physical therapist, will tell you how well (and safely) you stand and walk. And then working with a physical therapist can improve any balance issues.
It will also help to reduce the fall hazards around your home. Make sure you have adequate lighting so you can see where you are going, especially at night. Use rug tape or backing to hold down the edges of large rugs, and get rid of small throw rugs altogether. Move any electrical cords that you have to walk over. Check your stair railings to make sure they are sturdy and if not, have someone anchor them securely to wall studs.
