Osteoporosis Prevention & Treatment
Medications, Fluoride, Treatment
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) 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
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
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.