What are the controversies surrounding osteoporosis medications?
Medications used to treat osteoporosis are divided into 2 groups: 1. Drugs that help build bone and 2. Drugs that reduce bone loss. One of the most popular type of medications, bisphosphonates (Fosamax, Boniva, etc) actually do both. Unfortunately, there has been some questions and controversy surrounding the use of bisphosphonate medications over the last several years.
One of the major actions of bisphosphonate medications is to decrease bone breakdown. During the first year of taking this medication, the body continues to build bone. When we look at the bones with a DEXA scan, they appear denser. However, after the first year, the benefits of this medication become questionable. The action of shutting down bone breakdown also impairs the body’s natural bone repair mechanisms. This may be why after 5 years of use there are some reports of odd, non-traumatic fractures in women using this medication. Some experts question whether the risks of negative side effects, like inflammation of the esophagus and bone loss of the jaw, are worth the 1% reduction in fracture risk. Most doctors agree that they only recommend this medication for those women with osteoporosis (severe bone loss) rather than use it for prevention.
Another controversial medication for bone support is estrogen. Estrogen reduces bone breakdown, especially in the hip and spine. In 2001, the first reports from the Women’s Health Initiative, a large scale research study, revealed that estrogen replacement has some unwanted risks along with the benefits. This study revealed that estrogen increases the risk of blood clots and strokes. However, estrogen can also protect bone, lower the risk of coronary calcium and decrease the risk of colon cancer. Estrogen replacement may be an appropriate medication to use for bone protection for women under the age of 59 who are experiencing menopausal symptoms such as hot flashes and vaginal dryness.
Besides estrogen, calcitonin and parathyroid hormone are two other hormones that may help build bone. These hormones regulate both calcium and phosphate into the bone. Calcitonin (Calcimar and Miacalcin) is usually administered by a nasal spray. This is a good option for those who cannot tolerate bisphosphonates and are not good candidates for estrogen. The newer synthetic parathyroid hormone Forteo is administered by daily injection and is reserved for severe osteoporosis. This medication has not been around long enough to know all the possible negative side effects.
In general, we recommend following an alkaline diet, participating in bone building exercises, and taking targeted nutritional supplements to prevent bone loss. When our patients are faced with an osteoporosis diagnosis, we often discuss the pros and cons of these medications. We take careful consideration of a patient’s fracture risk compared to the risks and benefits of a medication. For each woman, the choice and treatment plan may be different.