Drugs to treat osteoporosis

Several types of medication are used to prevent fractures in people with osteoporosis, or “thinning” bones. Some are more effective at preventing certain types of fractures than others. But there’s little evidence that these medications will help if you have osteopenia, sometimes called “pre-osteoporosis,” which is bone density that’s lower than normal but not severe enough to be called osteoporosis.

In those cases, instead of medication, consider lifestyle changes. That includes making sure that your diet has adequate amounts of calcium and vitamin D, and doing weight-bearing exercise, such as walking or lifting weights. Also take precautions to prevent falls in the first place, such as limiting how much alcohol you drink and avoiding sleeping pills if possible. Consider medication only if your bone density worsens to the point where you have osteoporosis—although it’s still important to continue the lifestyle changes.

If your doctor diagnoses osteoporosis and recommends medication, we suggest the following Best Buy Drug after taking into account effectiveness, safety, convenience, and cost.

• Generic alendronate

The drug is available as a generic that costs $39 to $63 a month, depending on the dose. It has been shown to help prevent fractures of the hip, spine, and other bones in those with osteoporosis. It’s usually well tolerated, but as with all bisphosphonates, the "class" of drugs to which alendronate belongs, the most common side effects include diarrhea, nausea, vomiting, heartburn, esophageal irritation, and bone, joint, or muscle pain. Bisphosphonates can also cause rare but serious side effects that include permanent bone deterioration of the jaw (osteonecrosis) and, when taken for more than five years, a possible increased risk of thigh fracture. So talk with your doctor about how to reduce your risk of side effects.

Most studies of alendronate and the other osteoporosis medications have involved postmenopausal women with osteoporosis, so it’s not clear how well they work for men or younger women.

In this analysis, we focus on the medication most often prescribed to treat osteoporosis, a condition in which the inside of bones becomes thin and less dense, weakening them and making them more likely to fracture. There are usually no symptoms of osteoporosis, so people can be unaware that they have the condition until they break a bone. The danger of osteoporosis is that it can lead to fractures of the hip, spine, and wrist, which can be permanently disabling. And fractures have other consequences: One in five women age 50 and older who break a hip will die in less than a year, according to the Agency for Healthcare Research and Quality.

The 13 medications evaluated in this report are used to prevent thinning bones and fractures due to osteoporosis (see Table 1). They are bisphosphonates—alendronate (Fosamax and generic), ibandronate (Boniva and generic), risedronate (Actonel, Atelvia, and generic), and zoledronic acid (Reclast)—denosumab (Prolia), menopausal hormone therapy (estrogen or estrogen plus other hormones), raloxifene (Evista), and teriparatide (Forteo).

Most studies of these medications have involved postmenopausal women with osteoporosis, so it’s not clear how well they work for men or younger women. All of these drugs except teriparatide work by preventing the destruction of bone. Teriparatide works by stimulating the formation of new bone tissue, but it’s approved to use only for two years of treatment.

Table 1. Osteoporosis Medications Evaluated in This Report

Most of the drugs are available as tablets, but some come in other formulations. Alendronate (Fosamax), for example, is available as a tablet and a liquid; ibandronate (Boniva) comes in tablet form and as an injectable; denosumab (Prolia), teriparatide (Forteo), and zoledronic acid (Reclast) are injectables, and Premarin is available as a tablet, an injectable, and a cream. The so-called “injectables,” which require either an injection or intravenous infusion, tend to be more expensive, but they might be options if you are unable to take or tolerate pills.

The medications also vary in how often they are taken (see Table 6). Alendronate tablets come in lower strengths that are taken daily and higher strengths that are taken weekly; ibandronate pills are taken monthly, and the injectable medications range from once a day, to once every three months, to once a year.

That’s important, because studies have found that how often you have to take a medication can make a difference in whether you continue to take it. Only about half of the people who start a fracture-prevention drug continue with it after a year, but those who take a once-a-week drug are more likely to continue compared with those taking a drug daily. There’s not enough evidence to know whether a monthly or less frequent regimen is better than a weekly course.

Side effects are another important consideration. People often stop taking a fracture-prevention drug because of them. The side effects associated with these medications are discussed in more detail below.

Deciding whether you need a medication should begin with determining your risk of having a bone fracture. You and your doctor should consider factors that increase your risk, such as your age and race, whether you smoke, how much alcohol you regularly consumer, and family and medical history (see Table 2).

Your doctor will probably arrange for a test called a DXA scan, which uses an X-ray beam to measure bone density at your hips, spine, and possibly your wrists. But not everyone requires a DXA scan. Consumer Reports medical advisers say that women should have one at age 65, and men at age 70. Postmenopausal women under that age and men 50 and older should be screened only if they:

• Are unusually thin or smoke.
• Have had a fracture from a minor trauma or have a parent who had an osteoporosis-related fracture.
• Have a disease (thyroid or parathyroid disorders, celiac disease, adrenal hyperactivity) or regularly take medication, such as steroids or certain antiseizure drugs, that causes bone loss.

The DXA score is compared with the average score of 30-year-old women. The comparison, called a T-score, is expressed as standard deviations (SD) from that average. The lower the score, the higher the fracture risk. A T-score of minus 2.5 SD or less is considered osteoporosis; a score between minus 1 and minus 2.5 SD is considered osteopenia (or pre-osteoporosis), or bone density that’s lower than normal but not severe enough to be called osteoporosis. To make diagnoses more standard, the World Health Organization developed a calculator that uses DXA results plus other risk factors to predict a person’s 10-year probability of having a fracture. Known as FRAX, it is expected to shift treatment toward those who really need it. You can determine your risk of having a bone fracture here: http://www.shef.ac.uk/FRAX/.

Table 2. Factors that raise the risk of fracture

People who learn from the test that they have osteopenia or pre-osteoporosis can usually skip taking the medications evaluated in this report. There’s little evidence that they help if you have low bone density but not low enough to have osteoporosis. Instead, most people with low bone density are usually better off trying lifestyle changes to help preserve bone mass and prevent the development of osteoporosis (see Table 3). Consider medication only if your bone density worsens.

Lifestyle changes include a diet that contains adequate amounts of calcium and vitamin D, which help form and maintain strong bones. Calcium has been shown to prevent fractures of the hip but not other bones. Some research suggests that calcium supplements might increase the risk of a heart attack, but more studies are needed to determine if that is a real risk. Studies of whether vitamin D reduces fractures have had mixed results depending on the dose and the form of the vitamin used. But the evidence suggests that 700 to 800 I.U. of vitamin D daily, particularly when given with calcium, reduces the risk of hip and non-spine fractures.

Other steps to help prevent osteoporosis include doing weight-bearing exercises, such as walking or lifting weights, which can help strengthen your bones and reduce your chance of falling. And don’t smoke, because evidence shows that the habit can worsen bone loss.

Certain medications can also increase bone loss, including corticosteroid medications such as prednisone, the blood thinner heparin, and some drugs for epilepsy—carbamazepine, phenobarbital, phenytoin, primidone, and valproate, according to UpToDate.com, a physician website. Talk with your doctor about decreasing your dose or switching to a different medication if you take any of those.

Certain diseases, such as celiac disease, lupus, and rheumatoid arthritis, may worsen bone loss and increase the risk of osteoporosis, according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases. So if you suffer from other conditions, talk with your doctor about whether it increases your chance of developing osteoporosis and ways to reduce your risk.

Table 3. Lifestyle Changes to Help Prevent Fractures

The bisphosphonates, denosumab (Prolia), raloxifene (Evista), and teriparatide (Forteo) can help prevent fractures (see Table 4) in women with osteoporsis. But they pose a risk of side effects (see Table 5) and some are more effective at preventing fractures than others. They also differ in price (see Table 6), ranging from as little as $5 for a month’s supply to $1,500 or more a month. Menopausal hormone therapy has not been shown to reduce fractures in women with osteoprosis and it carries a risk of serious side effects.

Most studies have been conducted in postmenopausal women; there is less information about how well the drugs prevent fractures in men or younger women with low bone density.

As you can see in Table 4, all of the bisphosphonates have been shown to reduce the risk of fractures of the hip, spine, and other bones (with the exception of ibandronate; there’s no information on whether it prevents other fractures besides those of the spine). But there isn’t enough evidence overall to judge whether any of the bisphosphonates are superior than the others in preventing fractures.

Table 4. Effectiveness of Drugs to Prevent Fracture in Postmenopausal Women

_{* In studies of postmenopausal women with osteoporosis, estrogen did not reduce the risk of fractures. However a large, good quality study that included women whether or not they had osteoporosis showed it reduced the risk of hip and vertebral fractures, but was associated with serious harms.}

The most common side effects associated with bisphosphonates include diarrhea, nausea, vomiting, heartburn, esophageal irritation, and bone, joint, or muscle pain (see Table 5). Those medications can also cause rare but serious side effects that include osteonecrosis, or permanent bone deterioration of the jaw. Studies have found that this occurs in one to 28 people for every 100,000 taking the drug. Some studies have suggested that bisphosphonates increase the risk of esophageal cancer and certain types of thigh fractures when taken for more than five years, but more research is needed to determine whether those risks are due to the medication. Zoledronic acid can cause kidney failure in people with impaired renal function, and some research has found that it might increase the risk of a serious heart problem called atrial fibrillation, but it’s not clear if this is due to the medication.

Menopausal hormone therapy does not reduce the risk of fractures in women diagnosed with osteoporosis. And it actually increases the risk of stroke, heart disease, and breast cancer, so it’s generally not used solely to treat or prevent osteoporosis.

Only a few studies have compared bisphosphonates head-to-head with other fracture-prevention drugs, so we can’t say whether bisphosphonates are more or less effective than raloxifene or teriparatide in preventing fractures. But those other medications have not been shown to prevent as many different types of fractures as bisphosphonates, and they also cause side effects that rule them out as first options for osteoporosis.

Raloxifene has been shown to reduce the risk of spine fractures, but it’s no better than a placebo at preventing other kinds of fractures. Also, it increases the risk of life-threatening blood clots, hot flashes, and muscle pain.

Teriparatide reduces the risk of spine fracture and other non-spine fractures, but there’s no evidence that it helps prevent hip fractures specifically. Side effects include headaches, high calcium levels in the blood, and an increased risk of bone cancer when taken at high doses.

Denosumab reduces the risk of spine, hip, and other fractures compared with a placebo, but it hasn’t been compared head-to-head with other drugs for fracture prevention. Denosumab is associated with an increased risk of serious infection of the skin, abdomen, urinary tract, and ear; osteonecrosis of the jaw (similar to bisphosphonates); and low calcium levels.

Table 5. Side Effects of Fracture-Prevention Medication

_{Source: The Agency for Healthcare Research and Quality. Reducing the Risk of Bone Fracture: A Review of the Research for Adults With Low Bone Density.}

If your doctor diagnoses osteoporosis—not osteopenia or “pre-osteoporosis”—and recommends a medication, we suggest the following Best Buy after taking into account effectiveness, safety, convenience, and cost.

• Generic alendronate

It’s available as an inexpensive generic from $39 to $63 a month, depending on the dose. It has been shown to help prevent fractures of the hip, spine, and other bones. It’s usually well tolerated, but as with all bisphosphonates, the most common side effects include diarrhea, nausea, vomiting, heartburn, esophageal irritation, and bone, joint, or muscle pain. Bisphosphonates can also cause rare but serious side effects that include permanent bone deterioration of the jaw (osteonecrosis) and when taken for more than five years, a possible increased risk of having a thigh bone fracture. So talk with your doctor about how to reduce your risk of side effects.

If you’ve taken any bisphosphonate for five years or more, ask your doctor about taking a drug “holiday”—stopping temporarily—to encourage normal bone remodeling and to reduce the risk of side effects. At present, there’s no consensus among medical experts about the optimal length of time patients should take a bisphosphonate.

Osteoporosis drug prices

Note: If the price box contains a green $, that indicates the dose of that drug may be available for a low monthly cost through programs offered by large chain stores. For example, Kroger, Sam’s Club, Target, and Walmart offer a month’s supply of selected generic drugs for $4 or a three-month supply for $10. Other chain stores, such as Costco, CVS, Kmart, and Walgreens, offer similar programs. Some programs have restrictions or membership fees, so check the details carefully for restrictions and to make sure your drug is covered.

How we picked the 'Best Buys'

• Be approved by the FDA for treating osteoporosis.
• Have a safety record equal to or better than other osteoporosis medications.
• Have an average price for a 30-day supply that was substantially lower than the most costly fracture-prevention drug meeting the first two criteria.

These materials are made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multi-state settlement of consumer-fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).

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