Effective Medications For Treating Bone Loss

By: Harris H. McIlwain, M.D., and Debra Fulghum Bruce, Ph.D., with Laura McIlwain Cruse, M.D., and Kimberly Lynn McIlwain, M.D.

Your doctor says you are at high risk of fractures. Now what? You should consider taking one of several excellent new medications that help to prevent and treat bone loss. While there is no cure for osteoporosis, some medications can help prevent it, slow it down, or stop and reverse its progress altogether. Because bone density is strongly connected to an increased risk for fractures, we know that as bone density improves, the risk of fractures drops.

Most of the medications described below are proven to increase bone density and lower the risk of fractures. Some have also been proven to lower the risk of fractures in the spine and the hip. Many studies on the effectiveness of these medications have been done in postmenopausal women. Some of the studies were also done in men and in patients taking cortisone medications, which greatly increase the risk of osteoporosis. The risk of fractures dropped over six to twelve months. Many researchers believe that the quick improvement in fracture risk is due to microscopic changes in the structure of the bones that makes them stronger and less likely to break. These microscopic changes happen in addition to the improvement of the total amount of bone present.

The most effective medications to prevent fractures are listed below. These medications have been used mainly in postmenopausal women, but are being used as well in men with osteoporosis, in men and women who take prednisone, and in some perimenopausal women. Your doctor can help you decide whether any of them are appropriate for you.

Actonel (risedronate) is a bisphosphonate, a group of medications that reduces the activity of cells that cause bone loss, to produce a net increase in bone density. Unlike estrogen, the bisphosphonates are not hormones. Instead, bisphosphonates build overall bone mass by slowing the removal of bone while allowing more bone to continue to be formed. Over 95 percent of those treated with bisphosphonates increase their scores on bone density testing.

Actonel in particular has been shown to lower the risk of spinal fractures by up to 69 percent in one year. In clinical trials, Actonel decreased the chance of spinal fractures in patients taking cortisone medications by 70 percent in one year. It also reduced the risk of hip fractures in women with osteoporosis by about 60 percent after three years.

Fosamax (alendronate) is also a bisphosphonate. In clinical trials of postmenopausal women with osteoporosis, Fosamax reduced bone loss and increased bone density in both the spine and the hip. Fosamax also reduced the risk of spine fractures by up to 62 percent at two years and hip fractures by 56 percent at four years.

Fosamax and Actonel are usually taken once a week, but can also be taken daily. Once you are up for good in the morning, take it with a 6- or 8-ounce glass of water. Orange juice or coffee can decrease the amount of medication absorbed. It's important not to lie down for 30 to 60 minutes after taking Fosamax or Actonel. After that time you can drink or eat. This usually prevents any symptoms of esophageal irritation such as indigestion, heartburn, or abdominal discomfort.

Most people do not have problems taking one of these medications, but potential side effects include heartburn, indigestion, or abdominal discomfort; muscle, bone, or joint soreness or aches; other problems such as nausea, vomiting, diarrhea, or constipation are uncommon. If you already have an esophageal problem, especially a narrowing of the esophagus (esophageal stricture), check with your doctor before you take one of these medications.

Evista (raloxifene) is a selective estrogen receptor modulator (SERM) used to build bone in those with osteoporosis. Raloxifene is an anti-estrogen, meaning it blocks the effect of estrogens in breast cancer. The advantage of Evista is that it doesn't increase the risk of breast cancer, which is one reason women are now stopping HRT as a preventive measure against bone loss. Evista also does not cause uterine bleeding, which often occurs with hormone replacement therapy. SERMs are not estrogens, but they have estrogen-like effects on some tissues and anti-estrogen effects on other tissues. Evista has been shown to prevent bone loss, improve the score on bone density testing, and reduce the risk of spine fractures by 30 to 50 percent. It is taken as a tablet once a day.

Most women tolerate Evista without problems, but potential side effects include hot flashes, clot formation in some blood vessels, muscle soreness, weight gain, or a rash.

Miacalcin (nasal calcitonin) and Calcimar (calcitonin) are approved for the treatment of osteoporosis in women who are at least five years beyond menopause. Calcitonin is a hormone (but not an estrogen) that's involved in calcium regulation and bone metabolism. It is usually taken as a single daily nasal spray (Miacalcin) or sometimes as an injection under the skin (Calcimar). In postmenopausal women, calcitonin increases bone density, particularly in the spine. Some have found that Miacalcin (the nasal spray) increased bone density, especially in the first year, but had less effect in the second year of treatment. Studies have shown that Miacalcin lowered the risk of fractures in the spine by 36 percent.

Some patients find that calcitonin also helps relieve pain from spinal fractures.

The most common side effects reported with Miacalcin nasal spray are a runny nose and other signs of nasal irritation. Potential side effects of calcitonin include flushing of the face and hands, increased urinary frequency, nausea, and skin rash.

Forteo (teriparitide) is a synthetic version of parathyroid hormone, which is naturally produced in the body and stimulates bone formation. It actually builds new bone by increasing the activity and number of bone-forming cells called osteoblasts. All other approved osteoporosis treatments, including Fosamax, Actonel, Evista, Miacalcin, and estrogen, are antiresorptive -- that is, they slow the rate of bone loss by interfering with bone-destroying cells called osteoclasts.

In clinical trials, Forteo reduced the risk of spinal fractures by 65 percent at nineteen months. This medication is used in patients who have osteoporosis with a high risk of fractures, or for patients with osteoporosis who have failed to respond to or experienced side effects with other medications. It is given as a subcutaneous injection daily.

The most common side effects of Forteo are dizziness and leg cramps. It is not given for more than two years. Persons who have had Paget's disease (a disease of the bone), radiation treatment to bones, bone cancer, or high blood calcium levels should not take Forteo. As always, talk with your doctor about the benefits and risks of Forteo (or any treatment) to prevent fractures from osteoporosis.

Excerpted from the book Reversing Osteopenia: The Definitive Guide to Recognizing and Treating Early Bone Loss in Women of All Ages by Harris H. McIlwain, M.D., and Debra Fulghum Bruce, Ph.D., with Laura McIlwain Cruse, M.D., and Kimberly Lynn McIlwain, M.D. Copyright © 2004 Harris H. McIlwain, M.D., and Debra Fulghum Bruce, Ph.D.

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