Osteoporosis Medications: Benefits vs. Side Effects

There are many medication options to treat osteoporosis, a disease that weakens bones and makes them brittle and prone to breaking. When choosing the right medicine, several factors must be considered, including menopausal status, disease severity, and the drug's cost, risks, and delivery method—injection, oral, or intravenous (IV) infusion.

This article reviews the factors that go into choosing an osteoporosis drug. A list of osteoporosis medications, including their mode of action and side effects, is also provided.

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Osteoporosis Medications: Deciding Factors

Osteoporosis causes no symptoms, including pain (unless a fracture is present). Despite being a "silent" disease, medication may be necessary to reduce your fracture risk. Fractures can be devastating and are associated with a poor quality of life.

As you discuss osteoporosis treatment with your healthcare provider, the following factors will be taken into account.

Terminology

Verywell Health prefers to use inclusive terminology. But when citing health authorities or research, the terms for gender and sex from those sources are used. Food and Drug Administration (FDA) guidelines for drug indications often use binary gender terms.

In this article, "female" refers to people assigned female at birth, and "male" refers to people assigned male at birth. Talk to a healthcare provider to determine whether screening or a medication is indicated for you.

Menopause, Gender, and Age

Postmenopausal females are at high risk for developing osteoporosis and bone fractures because they have low estrogen levels.

In addition to menopause and declining estrogen levels, bones naturally weaken and thin with advancing age. As such, medication may be advised to treat postmenopausal females and males aged 50 years or older with osteoporosis.

Overall, patient sex and age both influence the choice of therapy. This is because some osteoporosis drugs are FDA-approved for both older males and postmenopausal females. Other osteoporosis medications are only approved for postmenopausal females. Likewise, some osteoporosis medications are better for younger postmenopausal females and others for older ones.

Extent of Bone Loss

The extent of your bone loss is reflected in your T score.

The T score is a number that compares your bone's quality with that of an average young person with healthy bones. Individuals with normal bone density have a T score between plus 1 and minus 1, whereas individuals with osteoporosis have a T score of minus 2.5 or less. 

Since osteoporosis medications work in distinct ways and have varying levels of effectiveness, the severity of your osteoporosis impacts your choice of therapy.

Side Effects and Personal Preferences

Osteoporosis medications have unique side effect profiles and contraindications (reasons not to take the drug). You may not be able to tolerate certain drugs, or they may be unsafe for you to take.

Moreover, osteoporosis medications differ in their delivery method and dosing schedules. You may prefer, for example, a pill vs. a shot or a monthly vs. daily medication.

Cost and Insurance Coverage

Insurance companies usually cover osteoporosis medication, but how much depends on your insurance type and co-pay. If you have Medicare, the cost of prescription drugs can be lowered through a benefit called Medicare Part D.

If you are considering an osteoporosis medication, check the medication or your insurance company's website to find out if it's covered. Your healthcare provider can also refer you to a social worker or billing specialist for assistance.

Length of Time on Medication and Monitoring

When taking an osteoporosis medication, your healthcare provider will monitor you periodically to see how well it works and evaluate for any adverse reactions.

Some individuals may need to change their drug, perhaps because they continue to lose bone or develop an intolerable side effect. Also, some medications can only be used for a certain length of time due to safety concerns or reduced benefits with long-term use.

The degree of monitoring required and the time you can take a drug can ultimately affect your choice.

List of Osteoporosis Medications

Osteoporosis medications work to prevent fractures by either slowing bone loss or forming new bone; however they cannot fully reverse the condition.

Here is a list of osteoporosis medications, including their mode of action and how they are taken. A summary chart that includes the drugs' common and serious side effects is also provided.

Bisphosphonates

Bisphosphonates are the most commonly used drugs to treat osteoporosis.

They are used to treat males and postmenopausal females with osteoporosis and steroid-induced osteoporosis (bone weakening caused by chronic steroid use, for example, prednisone).

Bisphosphonates work by slowing the natural breakdown of bone. Several types are available, varying in their dosing and delivery method (pill, liquid, or IV infusion).

Options include:

  • Binosto, Fosamax (alendronate): This pill is taken once daily or weekly.
  • Actonel, Atelbia (risedronate): This pill is taken once daily, weekly, or monthly.
  • Boniva (ibandronate): This pill is taken once daily or monthly or as an injection every three months.
  • Reclast (zoledronic acid): This IV infusion (through the vein) is given once a year.

For oral bisphosphonates, the pill must be taken in the morning on an empty stomach with 4 ounces (half a cup) of water. You then need to sit or stand upright for 30 minutes before eating. The purpose is to avoid irritating the esophagus (the tube that carries food from your mouth to your stomach.

Individuals who cannot follow these instructions or those with esophageal disorders should not take an oral bisphosphonate.

Bisphosphonates are generally taken for three to five years. Taking one for seven years or more may rarely increase the risk of an unusual bone break in the thigh bone (atypical femur fracture).  

Also, some people worry about developing a complication called osteonecrosis (death of a portion of bone) of the jaw with bisphosphonates. This risk is minimal and more common in individuals taking a bisphosphonate as part of their cancer treatment, not for osteoporosis.

Prolia (Denosumab)

Prolia (denosumab) is used in postmenopausal females at high risk for fracture or who have not responded to or tolerated other osteoporosis drugs.

High risk for fracture is generally defined as someone with a history of osteoporotic fracture or multiple risk factors for fracture,

Prolia is injected underneath the skin, usually by a healthcare provider, once every six months. It works by blocking a protein involved in the formation of cells that break bone down (osteoclasts).

Prolia can cause or worsen low calcium levels in the blood (hypocalcemia), so this abnormality must be corrected before starting Prolia (if present).

In addition, stopping Prolia is associated with rapid bone loss. As a result, a drug holiday (taking time off from using the drug) is not advised for people taking Prolia. If the drug needs to be stopped, a bisphosphonate is usually prescribed to preserve bone density.

Evista (Raloxifene)

Evista (raloxifene) is a type of drug called a selective estrogen receptor modulator (SERM).

What Is a SERM?

A SERM is an estrogen-like medication that mimics estrogen in some parts of the body and blocks the effects of estrogen in other parts. 

Evista can slow down bone loss in postmenopausal females and is taken as a pill once a day.

Evista increases the risk of death due to stroke in postmenopausal females with (or those at risk for) stroke. It also increases the risk of blood clots in your legs (deep vein thrombosis). lungs (pulmonary embolism), and eyes. As such, females at risk for stroke or blood clots should not take this medication.

Parathyroid Hormone/Parathyroid Hormone-Related Protein

Forteo (teriparatide) or Tymlos (abaloparatide) are approved for postmenopausal females at high risk for fracture.

Forteo is also FDA-approved for males at high risk for fractures and for treating osteoporosis in people of any sex associated with long-term steroid therapy (taking 5 milligrams or more of prednisone daily).

Forteo and Tymlos work by stimulating bone formation. They are given as daily injections underneath the skin and are available in prefilled syringe pens so people can administer the shots themselves at home.

Forteo and Tymlos are used for up to two years. This restriction is due to the possible risk of developing osteosarcoma (a type of bone cancer). Keep in mind, though, osteosarcoma has only been seen in studies of animals, not humans.

Evenity (Romosozumab)

Evenity (romosozumab) may treat postmenopausal females at a high risk of fractures. A healthcare provider gives Evenity as a monthly injection underneath the skin.

Evenity enhances bone formation by blocking sclerostin, a protein that stops building new bone. The drug can only be used for up to one year because it becomes less effective at reforming bone.

Also, Evenity may increase the risk of heart attack and stroke, although it's unclear why. Until more is known, the drug should not be given to people with a history of or an increased risk of heart attack or stroke.

Summary of Osteoporosis Medications
  Delivery Dosing Common Side Effects Serious Side Effects
Oral or Injected Bisphosphonate (e.g., Fosamax, Actonel, Boniva) Pill or injection Daily, weekly, monthly, or every three months (injection) Back pain, joint/arm/leg pain, nausea, heartburn, stomach pain, Severe esophageal inflammation, severe muscle/joint/bone pain, low blood calcium levels, jaw osteonecrosis, atypical femoral fracture
Reclast (zoledronic acid) Infusion Yearly Fever, muscle/joint aches, headache, arm/leg pain Low blood calcium levels, jaw osteonecrosis, atypical femoral fracture, severe muscle/joint/bone pain
Prolia (denosumab) Injection Every 6 months Back pain, arm/leg pain, muscle/joint pain, high cholesterol, bladder infection Low blood calcium levels, jaw osteonecrosis, atypical femur fractures, serious infections
Evista (raloxifene) Pill Daily Hot flashes, leg cramps, leg swelling, flu-like symptoms, joint stiffness, sweating Increased risk for blood clots and death due to stroke in patients with (or at risk for) stroke
Forteo (teriparatide) Injection Daily Joint stiffness, pain, nausea, high calcium levels Osteosarcoma (in animal studies)
Tymlos (abaloparatide) Injection Daily Calcium in the urine, dizziness, nausea, headache, palpitations, unusual tiredness, stomach pain Osteosarcoma (in animal studies)
Evenity (romosozumab) Injection Monthly Joint stiffness, headache Low blood calcium levels, jaw osteonecrosis, atypical femur fractures, may increase risk of heart attack and stroke
Source

Medication Alternatives

There is limited scientific evidence supporting the benefits of alternative treatments for osteoporosis, including taking traditional Chinese medicine herbs or engaging in practices like yoga and acupuncture.

That said, these therapies may be reasonable to incorporate into your osteoporosis treatment plan, mainly if they help you feel better. Before starting any new treatment, always discuss it first with a healthcare provider. You want to be sure the therapy is safe and proper for your care.

An Integrative Approach to Osteoporosis Treatment

Osteoporosis cannot be fully cured or reversed, but there are things you can do to slow bone loss and help rebuild bone tissue.

Take an integrative approach, which includes healthy lifestyle behaviors and, sometimes, medication.

Healthy lifestyle behaviors include:  

  • Eat a well-balanced diet plentiful in fruit and vegetables that include calcium, vitamin D, and protein. Supplements, especially vitamin D, may be needed.
  • Participate in regular exercise. Include weight-bearing exercises (e.g., walking or playing tennis) and resistance exercises (e.g., lifting weights).
  • Avoid secondhand smoke, and quit smoking if you do.
  • Drink alcohol in moderation, which means no more than one drink a day for females and no more than two daily drinks for males.
  • Engage in fall-prevention strategies (e.g., declutter, remove rugs, improve room lighting, wear supportive shoes).

Summary

Osteoporosis is associated with bone thinning and weakening, which makes bones prone to breaking. Treatment with medication is sometimes recommended to prevent bone breaks.

Several drugs are available, including bisphosphonates, estrogen-like medications, and parathyroid hormone. These drugs vary in their modes of action, delivery method, dosing schedule, and side effects. Such factors must be carefully considered when making the decision about the right therapy for you.

Frequently Asked Questions

  • Can you treat osteoporosis without medication?

    Healthy lifestyle habits, such as regular exercise and eating a well-balanced diet, are essential for strengthening your bones. However, for some individuals with osteoporosis, medication may be advised to augment this effect and further protect against fractures.

  • What is the newest osteoporosis medication?

    The osteoporosis medication Evenity (romosozumab) was FDA-approved in 2019 to treat osteoporosis in postmenopausal females at high risk of breaking a bone.

  • Which osteoporosis medication is the safest?

    Osteoporosis drugs have different risks and side effects profiles. Generally speaking, a bisphosphonate, like Fosamax or Actonel, is the first choice when choosing a medication for osteoporosis.

12 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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By Colleen Doherty, MD
 Colleen Doherty, MD, is a board-certified internist living with multiple sclerosis.