Osteoporosis Prevention & Treatment
Medications, Fluoride, Treatment Monitoring

1. Osteoporosis Slideshow Pictures
2. Super Foods for Your Bones Slideshow Pictures
3. Take the Osteoporosis Quiz

• SECTION 1
• Introduction
• Calcium and Vitamin D

• SECTION 2
• Exercise, Cigarette Smoking, and Alcohol
• Estrogen Replacement Therapy

• SECTION 3
• Medications that Prevent Bone Breakdown
• Fluoride
• Monitoring Treatment Success

MEDICATIONS THAT PREVENT BONE BREAKDOWN

MedicineNet: Now that we know about prevention of osteoporosis, tell us about the medications in the treatment of osteoporosis.

Dr. Truong: Aggressive prevention and treatment of osteoporosis can involve medications that work by preventing natural breakdown of bone or medications that promote new bone formation. Examples of medications for the treatment of osteoporosis that prevent natural bone breakdown (anti-resorptive agents) include alendronate (Fosamax), risedronate (Actonel), etidronate (Didronel), and calcitonin. A medication designed to promote new bone formation is teriparatide (Forteo).

The bone is a living dynamic structure; it is constantly being removed (resorbed) and rebuilt. This process is an essential part of maintaining the normal calcium level in the blood. When the rate of resorption exceeds that of rebuilding over time, osteoporosis results. Anti- resorptive medications inhibit bone removal or resorption. This tips the balance toward bone rebuilding, thus increasing bone mass.

Alendronate (Fosamax) is an effective antiresorptive medication approved by the FDA for treating osteoporosis in women. Alendronate has been shown to increase bone density in the spine, and around the hips and arms. Alendronate also reduces the risk of fractures in the spine, hips, and wrists. The bone strengthening benefits of Fosamax can even be seen in elderly women over 75 years of age.

Fosamax is generally well tolerated with few side effects. One side effect of Fosamax is irritation of the esophagus (the food pipe connecting the mouth to the stomach). Inflammation of the esophagus (esophagitis) and ulcers of the esophagus have been reported infrequently with Fosamax use.

Risedronate (Actonel)

Risedronate (Actonel) is another bisphosphonate anti-resorptive medication. Like alendronate, this drug it is approved for the prevention and treatment of postmenopausal osteoporosis as well as for osteoporosis that is caused by cortisone-related medications (glucocorticoid-induced osteoporosis). Risedronate is chemically different from alendronate and has less likelihood of causing esophagus irritation. Risedronate is also more potent in preventing the resorption of bone than alendronate. Ibandronate is the most recently approved bisphosphonates, and is approved for prevention and treatment of postmenopausal osteoporosis. It is available in both daily and monthly formulas.

I generally avoid prescribing Fosamax and Actonel for patients with a history of inflammation, ulcers, or scarring of the esophagus. To reduce side effects they should be taken on an empty stomach, with at least 8 ounces (240 ml) of water, while sitting or standing. This minimizes the chances of the pill being lodged in the esophagus. Patients should also remain upright for at least 30 minutes after taking these pills to avoid reflux into the esophagus.

For those patients who cannot tolerate the esophagus side effects of Fosamax, estrogen, etidronate (Didronel), and calcitonin are reasonable alternatives.

The FDA first approved etidronate (Didronel) for treating Paget's disease. Paget's disease is a bone disease characterized by a disorderly and accelerated remodeling of the bone, leading to bone weakness and pain. But the FDA has not approved Didronel for the treatment of osteoporosis. For many years, doctors in this country have been using Didronel to treat osteoporosis "off label"-that is, using it without formal FDA approval, because of its effectiveness.

Didronel has been shown to increase bone density in postmenopausal women with established osteoporosis. Didronel has also been found effective in preventing bone loss in patients requiring long term steroid medications (such as Prednisone or Cortisone). Didronel does not appear to cause esophagus side effects like Fosamax, but it can cause nausea and diarrhea.

High dose or continuos use of Didronel can cause another bone disease called osteomalacia. Like osteoporosis, osteomalacia can lead to weak bones with increased risk of fractures. Therefore, Didronel is only prescribed in small doses and in a cyclic fashion. For osteoporosis, it is given two weeks every three months rather than on a daily basis.

Because of osteomalacia concerns and lack of enough studies yet regarding reduction in the rate of bone fractures, the United States FDA has not approved Didronel for the treatment of osteoporosis.