6 Drug Treatments for Osteoporosis

Living with osteoporosis can be debilitating and everyone responds to pain differently, so pain relief that works for one person may not be effective for another. But some acute pain and chronic pain can respond well to pain-relieving medications such as paracetamol, anti-inflammatory medications such as ibuprofen, and codeine, which can all be purchased without a prescription. Sometimes pain is more severe and your doctor will need to prescribe stronger pain-relieving drugs.

Learning and using self-help strategies can also play a valuable part in helping to lessen the impact of chronic pain that cannot be relieved completely. Experiencing pain can lead to difficulties with sleeping, low mood and tension. In turn, feeling tired, emotionally low and stressed can make pain more difficult to manage. Tissues around the fracture have been affected and can take a long time to get back to normal. Do remember, though, that most people in time make a good recovery.

What’s more, new drug treatments for osteoporosis are being developed all the time, as scientists look at the factors that influence the bone remodelling process. Many drugs are also undergoing testing.

Some drug treatments for osteoporosis help to strengthen your bones and reduce your risk of fractures. Others have ways of working that are less well understood but which might combine both of these. The main aim of these drug treatments is to decrease the risk of breaking bones, and drugs are licensed on the basis that they do this. Often, treatments will show an increase in bone density as well.

Most drug treatments are not given to help reduce pain from fractures, but to slow down the activity of cells that break down old bone. In Chapter 2, we learned about the normal function of bone and how the bone-reabsorbing cells (osteoclasts) reabsorb more bone than is made by the bone-building cells (osteoblasts), leading to an imbalance of bone turnover. Drug treatments aim to decrease the risk of breaking bones, and some treatments have been shown to actually increase bone density. Some stimulate the cells that build new bones (osteoblasts) and are known as anabolic drugs. Others work by slowing down the activity of the cells that break down bones (osteoclasts), and these are known as antiresorptive drugs.

It is important for each of us to ask questions and to make an informed decision regarding individual drug treatments. There is an assortment available on the NHS and there are many factors for you to personally consider regarding drug treatment for your bones. The final decision will be yours, but many people are worried about possible side effects and long-term risks to health. As with any medication, osteoporosis drugs can potentially cause side effects, but these risks are usually smaller than the risk of experiencing fracture if you don’t take them. Some people may prefer not to take treatment, and will prefer instead to change their eating habits and take exercise, which can both have a positive effect on their bones. Lifestyle changes are certainly important, so you will need to balance the risks involved in both approaches.

If you do go down the drugs route, there will be a further decision to make: what type of drug will suit your needs best? This could take the form of a tablet, drink, injection or infusion drip. The important thing is to choose a treatment that you are happy with, because you may be taking it for a minimum of 5 years – and, if your risk is high enough, for up to 10 years – following which you will have a review. Sometimes the decision will depend on other existing medical problems you have, which might make some drug treatments unsuitable.

The treatment your doctor is able to prescribe for you will also be influenced by local or NHS guidance. Guidance in the UK is produced by the National Institute for Health and Care Excellence (NICE). NICE ensures that the treatment is beneficial in reducing fractures and is also cost-effective. A generic drug may be available, rather than a branded version, and this will be cheaper for the NHS. Not all treatments for osteoporosis have a specific licence for use by men, although many of them are suitable for use by both men and women, especially for those at high risk of fracture, or for those who have already broken bones.

Premenopausal women and younger men (under 50 years of age) will not usually be given drug treatment, because it’s thought they are unlikely to fracture in the near future. Low bone density in younger people may be caused by other factors, such as the eating disorder anorexia nervosa. These people may need specialist advice and guidance or other help and support to manage their underlying problems. Hormone Replacement Therapy may be given to those young women whose low body weight means that they do not have menstrual periods, and others will be recommended to take a calcium and vitamin D supplement if they are not getting enough in their diet.

The type of drug and duration of time for taking it will vary greatly according to an individual’s medical health, age, risk assessment and sex. If you have already been taking an osteoporosis drug for many years, it’s considered a good idea for your doctor to do a treatment review to consider if your drugs are still needed, or if there is concern about side effects. Taking your drugs correctly, regularly and as prescribed is all-important and will reduce the risk of side effects. Understanding why the instructions are important and following them carefully will ensure you get the most from your medication.

Commonly prescribed drugs

Seven drugs are widely prescribed:

• alendronate (alendronic acid, sold under the brand name Fosamax)

Alendronate is one of the bisphosphonate drug treatments widely used to reduce the risk of broken bones in people with osteoporosis. Most people take it as a weekly tablet, but it is also available as a weekly oral solution, effervescent tablet or daily tablet.

• raloxifene (sold under the brand name Evista)

Raloxifene is used to reduce the risk of broken bones in women with osteoporosis. It is taken as a daily tablet, swallowed whole at any time with or without food.

• risedronate (sold under the brand name Actonel)

Risedronate is one of the bisphosphonate drug treatments widely used to reduce the risk of broken bones in people with osteoporosis. It is available as a daily or weekly tablet. Most people take it as a weekly tablet.

• denosumab (sold under the brand name Prolia)

Denosumab is a drug treatment used to reduce the risk of broken bones in people with osteoporosis. It is given as a subcutaneous injection (just under the skin) every 6 months. When you have finished your course of injections, you will need to move on to another treatment.

• zoledronic acid (zoledronate, sold under the brand name Aclasta)

Zoledronic acid is one of the bisphosphonate drug treatments used to reduce the risk of broken bones in people with osteoporosis. It is given as an intravenous infusion (drip) once a year, usually in a hospital clinic, although some GP surgeries may also have facilities to give intravenous drugs. The drug is given slowly, typically over 15 minutes via a needle inserted into a vein. Your doctor will usually only recommend this infusion if bisphosphonates in tablet form are unsuitable. If zoledronic acid is prescribed and you have recently broken your hip, it is recommended that zoledronic acid is given two or more weeks after your hip repair surgery.

• ibandronate (sold under the brand name Bonviva)

Ibandronate is one of the bisphosphonate drug treatments widely used to reduce the risk of broken bones in people with osteoporosis. It is available either as a monthly tablet or as an injection into a vein. The injection, which will be given by a healthcare professional, comes in a pre-filled syringe (3mg dose in 3ml of fluid) and is given once every three months. The drug is given via a small needle that is placed in a vein in the arm or the back of your hand. It is likely that referral to an appropriate hospital consultant will be needed and that the procedure will take place in a hospital or clinic setting, although some GP surgeries may also have facilities to give intravenous drugs.

• Parathyroid Hormone Treatment (teriparatide, sold under the brand name Forsteo)

Parathyroid hormone is naturally produced by the body to help with the regulation of calcium. It is used to reduce the risk of broken bones in people with osteoporosis, and is given as a daily subcutaneous injection (a small injection under the skin).

Whichever drug you are prescribed, make sure you take the tablets regularly. Missing the odd tablet will probably not have an impact on your bone health in the long run, but you should avoid this if you can. If you are taking a weekly tablet such as alendronate, it is useful to choose a day that you will remember every week – for example, the day your bins are emptied or a memorable day such as a Sunday. If you continually forget or struggle to take your medication, it would be sensible to speak to your doctor about other treatment options that you may find easier to take. Reduce the risk of side effects by taking your drug treatment correctly.

Bisphosphonate tablets must be swallowed whole with a full glass of water, on an empty stomach, before any other medication and at least an hour before any other food or drink, while staying upright (sitting or standing) for at least 30–60 minutes, thus ensuring that the tablet does not stick in your gullet, where it can cause irritation. It is important to ensure that your osteoporosis drug is properly absorbed. Some drug treatments for osteoporosis (strontium ranelate and bisphosphonates such as alendronate) are very poorly absorbed, so if you eat or drink anything apart from water around the time you take your medicine, the drug won’t be absorbed and therefore won’t work to strengthen your bones. To maximise this absorption process, it is important to observe the fasting instructions described in the leaflet that comes with your medication. If you are taking a calcium supplement, it is particularly important that you do not take it at the same time of day as these osteoporosis drugs, as calcium will prevent their absorption. In some cases the doctor might consider a pause in your treatment, and after a while (usually one to three years) will reassess whether or not you should restart it. This may well be because your risk of fracture has been reduced but is not low enough for you to stop taking the drugs altogether.