Osteoporosis Treatment

There are two types of bone cells that are actively involved in removing old bone and replacing it with new bone: osteoclasts (breaks down bone) and osteoblasts (makes new bone). The most commonly prescribed medications for osteoporosis are antiresorptive drugs, known as bisphosphonates. These drugs limit bone loss by inhibiting osteoclast function. Bisphosphonates don’t rebuild bone but stabilize bone loss.

Some common oral bisphosphonates include:

• Alendronate (e.g., Fosamax)
• Risedronate (e.g., Actonel, Atelvia)
• Ibandronate (e.g., Boniva)
• Zoledronic acid (e.g., Reclast, Zometa)

Zolendronic acid is a newer treatment injected intravenously once a year directly into the bone. It may be preferable for people who cannot swallow pills or who have experienced adverse side effects from oral medications.

What is a bisphosphonate holiday?

The long-term use of drugs that help prevent bone loss (known as bisphosphonates) may damage the structural integrity of the bone matrix structure and has been associated with spontaneous femur and hip fractures. To prevent these rare but potentially debilitating injuries, your physician may suggest a "holiday" from your medication.

Raloxifene (e.g., Evista) is an oral selective estrogen receptor modulator that mimics the bone-building effects of the body’s own estrogen. It is given only to women, improves bone mineral density, and has been shown to prevent spine fractures.

Denosumab (Prolia, Xgeva)
Approved by the FDA in 2010, denosumab (e.g., Prolia, Xgeva) is a human monoclonal antibody. It is an antiresorptive drug that acts on a different molecular pathway than bisphosphonates (which are also antiresorptive drugs). Specifically, denosumab prevents the maturation of osteoclasts by binding to and inhibiting certain cell surface molecules.

The drug is administered subcutaneously in the upper arm (like a vaccine) twice a year.

Romosozumab (Evenity)
Approved by the FDA in 2019, romosozumab (Evenity) is a human monoclonal antibody, different from other FDA-approved bone therapeutic drugs in that it both builds bone and reduces bone resorption. It is indicated for the treatment of osteoporosis in postmenopausal women at high risk for fracture.

Evenity is administered subcutaneously once a month for 12 months. Continued therapy with an antiresorptive agent, such as alendronate or denosumab, following the 12-month period should be considered as this was what was done in the randomized controlled trials.

Abaloparatide (Tymlos)
Abaloparatide is a human parathyroid-related protein that, in April 2017, became the second FDA-approved medication that is classified as an anabolic therapy, shown to directly stimulate osteoblastic formation of new bone. Injected under the skin on a daily basis, this medicine improves bone density and helps to prevent bone fracture in postmenopausal women. It is currently approved by the FDA for use up to two years in postmenopausal women with osteoporosis who are at high risk for fracture.

Teriparatide (Forteo)
Teriparatide is a form of the human parathyroid hormone that stimulates the formation of new bone. In 2002, it was the first anabolic therapy for osteoporosis approved by the FDA. The hormone is injected into the body once daily for up to two years and is approved as a second-line treatment of postmenopausal osteoporosis.

It can also be prescribed to increase bone mass in men with primary or hypogonadal osteoporosis at high risk of fracture. In 2009, the FDA expanded teriparatide’s indication to include treatment for glucocorticoid-induced osteoporosis.

Testosterone
Low testosterone levels may cause osteoporosis in men. For low-testosterone men, doctors may prescribe testosterone replacement to build bone mass.