How Osteoporosis Is Treated

Osteoporosis treatment involves the use of effective osteoporosis medications to slow bone loss, increase bone density, and lower the risk of fractures. Fortunately, there are several categories of medications to choose from, some of which may be more effective for certain people than others. Good nutrition and regular weight-bearing exercise are also critical to supporting good bone health and managing the disease—so much so that healthcare providers prescribe them as part of an osteoporosis treatment plan.

Each case is different, but one thing holds when it comes to any osteoporosis treatment regimen—the sooner it is started, the better.

Home Remedies and Lifestyle

Osteoporosis is a chronic disease. Managing it appropriately involves lifestyle changes to build and maintain bone density.

Proper Nutrition

You must give your body what it needs to build healthy bones. The two essentials:

• Calcium: The vast majority of the body’s calcium is found in your bones. Milk and dairy products are obvious sources of calcium, but don’t overlook dark leafy greens, nuts, beans, and seafood, which are good sources in their own right.
• Vitamin D: This key nutrient helps the body absorb calcium. Good sources of vitamin D include fortified milk, eggs, fatty fish, and sunlight exposure.

On the other hand, there are other elements of a diet that can interfere with calcium levels and, thus, your bone-building efforts. Key ones to know about:

• Sodium: High-salt diets also increase the excretion of calcium.
• Oxalate: This compound is found in foods like spinach and sweet potatoes and can interfere with calcium absorption from these foods.
• Phosphorus: Most of this mineral is stored in your bones. Phosphorus intake does not directly affect calcium absorption; rather, high levels of phosphorus (especially with low calcium intake) can decrease bone formation and increase bone resorption, ultimately affecting bone metabolism in a negative way.
• Cola: Regular intake of cola (but not other carbonated soft drinks) has been associated with lower bone density. Colas contain phosphoric acid and may displace other beverages, such as milk, that might provide calcium.

Caffeine intake has been associated with bone loss in some studies, but the impact is not as notable.

Weight-Bearing Exercise

Weight-bearing exercise helps strengthen the bones and protects against further bone loss. Not all exercise is created equal in this regard, though. Weight-bearing or high-impact exercise is what stimulates bone regeneration.

Another benefit of regular exercise is that it builds muscle and increases coordination and balance. These all help minimize your risk of falling, which is a common way for people with osteoporosis to fracture bones.

Prescriptions

Osteoclasts are cells that break down and remove bone, while osteoblasts are cells that build bone. Most of the time there is a balance between them, thanks to parathyroid hormone (PTH), so that, after childhood, bones stay roughly the same size and density over time.

There are several different types of medications that may be used for osteoporosis, depending on the cause of your bone loss and other factors. Common types of medications include bisphosphonates, selective estrogen receptor modulators, calcitonin, parathyroid hormone (PTH) therapies, and monoclonal antibody therapies. A new class of medication called sclerostin inhibitors is also available to treat osteoporosis, following the FDA approval of Evenity (romosozumab) in 2019.

These drugs work in different ways to affect these factors to build bone and/or prevent loss. While taking more than one may seem like a good idea, there is little evidence that combining more than one class of these drugs is of benefit, though there are a few exceptions.

Osteopenia is not as severe as osteoporosis, but is on the spectrum of bone loss. Those who have it are at an increased risk of developing osteoporosis or fracture and may wish to consider treatment options as well. When used to treat osteopenia, the doses of some of these medications (but not all) are lower than those used for osteoporosis. However, due to the risks and side effects of the medications, healthcare providers often encourage starting with weight-bearing exercises and calcium for these individuals.

Bisphosphonates

Bisphosphonates are a category of osteoporosis medications that first became available in the 1990s. These drugs reduce the activity of osteoclasts (stop the destruction of bone) to reduce bone loss. This results in a net increase in bone density.

Specific drugs, however, differ in their likelihood of preventing certain fracture types, how they are used, and some of the common side effects.

Oral medications in the bisphosphonate class include the following.

• Actonel (risedronate): Actonel has been demonstrated to significantly reduce the risk of both hip and spinal fractures.
• Fosamax (alendronate): Fosamax has also been shown to reduce bone loss and the risk of spine fractures. This medication is available in both daily and weekly doses.
• Boniva (ibandronate): Boniva is a bisphosphonate that can be taken daily or once-per-month orally and is also available by injection given once every three months. It also reduces vertebral fractures.

People are instructed to take these drugs with water (orange juice and coffee can interfere with absorption) and remain upright afterward for at least 30 to 60 minutes.

Biophosphonate infusions include:

• Reclast (zoledronic acid)
• Zometa (zoledronic acid)

These are given only one time per year (for osteoporosis) as an infusion. The medication is administered through a needle inserted into a vein in your arm. The process lasts about 15 minutes.

Side effects of bisphosphonates depend on the particular drug, as well as how it is given. With oral medications, indigestion, heartburn, headaches, muscle pain, and esophageal inflammation may occur.

Side effects after infusions can include flu-like symptoms, headache, or sore muscles or joints. These side effects generally last just a few days after treatment. An uncommon side effect, especially with Reclast or Zometa, is osteonecrosis of the jaw. Other uncommon but serious side effects may include femur fractures and atrial fibrillation.

Selective Estrogen Receptor Modulators

Selective estrogen receptor modulators (SERMS) are interesting drugs in that they have estrogen-like effects on some tissues (such as bone) and anti-estrogen effects in others (such as breast tissue). Because of this, they may strengthen bones, similar to hormone replacement therapy.

Evista (raloxifene) is a SERM approved by the FDA to treat osteoporosis in women. It’s taken once a day in pill form. Evista slows bone loss and reduces the risk of spine (but not hip) fractures.

Since estrogen replacement therapy has been linked to breast cancer, Evista provides the benefit of estrogen to the bones without the risk of breast cancer or uterine bleeding found with hormone replacement therapy.

The drug can perform double-duty for women who have both osteoporosis or osteopenia and an increased chance of developing breast cancer.

Side effects include hot flashes, leg cramps, increased sweating, and headaches. The medication should not be used by those who have had blood clots in their legs (deep vein thrombosis), lungs (pulmonary emboli), or eyes (retinal vein thrombosis).

Hormone Replacement Therapy

Once touted for its ability to reduce the risk of osteoporosis, hormone replacement therapy (HRT) with estrogen has fallen out of favor due to it being associated with the risk of cardiovascular disease, dementia, genito-urinary problems, endometrial and ovarian cancer, and venous thromboembolism.

That said, some women continue to use HRT to control menopausal symptoms, and it has clearly been shown to improve quality of life for some people. For those who use HRT for this reason, an added benefit is a reduction in bone loss.

Calcitonin

Calcitonin is a hormone naturally present in your body that works to regulate calcium and bone metabolism. Calcitonin inhibits osteoclast activity and increases renal excretion of calcium, which decreases the resorption of bone matrix and serum calcium levels.

Calcitonin is approved for the treatment of osteoporosis in women who are at least five years beyond menopause. It increases bone density, particularly in the spine, and appears to reduce the risk of spine fractures. It may also reduce pain for people who have fractures.

The effect is greatest in the first year of treatment and falls off rapidly after that time. Healthcare providers often recommend using a vitamin D and calcium supplement along with these medications—check with your practitioner about whether you should take one.

Calcitonin medications are available as a nasal spray or an injection, including the brand name Miacalcin. Miacalcin is available only as an injection. It is approved for Paget’s disease (a disease of the bone), hypercalcemia (elevated calcium level in the blood), and postmenopausal osteoporosis in women.

Side effects of the nasal spray may include nasal irritation, and calcitonin can cause skin flushing, a rash, nausea, and urinary frequency.

Parathyroid Hormone (PTH) Therapies

Parathyroid hormone is also naturally produced in the body. It stimulates bone formation by increasing the activity and number of osteoblasts, the bone-forming cells, and by minimizing the function of osteoclasts, reducing bone resorption.

Parathyroid hormone is most commonly prescribed for people who have been diagnosed with osteoporosis and who have a high risk of fractures, have failed to respond to other medications, or have experienced side effects with other osteoporosis drugs.

Studies show that the parathyroid hormone was found to reduce the risk of vertebral and nonvertebral fractures in postmenopausal women.

Parathyroid hormone medications include the following.

• Forteo (teriparatide): Forteo is a synthetic version of parathyroid hormone that is given as a daily injection. It was approved in 2002.
• Tymlos (abaloparatide): Tymlos is actually a synthetic version of part of the PTH protein. It was approved in 2017 for the treatment of severe osteoporosis, defined as a history of fractures, having multiple risk fractures, and/or having exhausted other osteoporosis treatment options. In addition to reducing the risk of spinal fracture, studies also found a reduction in non-spinal fractures.

The most common side effects of Forteo are dizziness and leg cramps. Tymlos has been associated with kidney stones due to increased calcium in the urine. 

It’s recommended that use of parathyroid hormone be limited to two years. Parathyroid hormone should not be used for those who have Paget’s disease, bone cancer (osteosarcoma), hypercalcemia, or who have had radiation treatment to their bones. In clinical trials, there appeared to be an increase in bone cancer in rats, which is why these drugs carry a boxed warning.

Both Forteo and Tymlos are very expensive relative to other options: treatment may cost up to $20,000 per year.

Following treatment (up to two years), it’s recommended that a bisphosphonate be started to maintain the increase in bone density. An overlap of six to 12 months may be beneficial.

Monoclonal Antibody Therapy

The category of monoclonal antibody therapy includes two medications with the same structure but different indications.

Denosumab is a synthetic antibody that prevents osteoclasts from forming. These drugs work by slowing the breakdown of bone and bone remodeling.

Monoclonal antibody therapies include the following.

• Prolia (denosumab): Prolia is available as an injection given once every six months. It may be prescribed for men and postmenopausal women with osteoporosis who have a high risk of fractures. As a preventive measure, Prolia may be used for adults receiving aromatase inhibitor therapy for breast cancer and men with non-metastatic prostate cancer who are receiving androgen deprivation therapy.
• Xgeva (denosumab): Xgeva is available as an injection given once every four weeks. Xgeva is approved for people with advanced breast cancer to reduce the risk of fractures related to bone metastases, to treat pain, and to reduce the risk of further fractures. It may also be used for people who have hypercalcemia of malignancy and those with giant cell tumors of the bone (in both cases, with different dosing).

The most common side effects of these drugs include back, joint, and muscle pain, along with increased cholesterol levels and urinary tract infections.

Adverse effects may include osteonecrosis of the jaw, an increased risk of infections (especially of the heart muscle), the potential for atypical fractures, and slow wound healing.

Here, too, additional use of a bisphosphonate may be recommended for a duration of a few months to a year.

Over-the-Counter (OTC) Therapies

With many osteoporosis medications, it’s recommended that people get adequate amounts of calcium and vitamin D.

• Calcium supplements: If you don’t get enough in your diet, your healthcare provider may suggest taking these. Calcium supplements are generally well tolerated and safe.
• Vitamin D supplements: Vitamin D is harder than calcium to get, even with a healthy diet (think several glasses of milk and salmon each day), and not everyone is able to get an adequate amount via sunlight outdoors. Talk to your practitioner about checking your vitamin D level (it’s a simple blood test) and adding a vitamin D3 supplement to your diet, if needed.

While adequate amounts of calcium and vitamin D are required for proper bone formation, they are not a substitute for the use of osteoporosis medications.

Surgeries and Specialist-Driven Procedures

When osteoporosis causes fractures, more aggressive treatment may be needed to address the injury and improve the integrity of the bone.

Vertebroplasty and Kyphoplasty

Vertebroplasty is a minimally invasive procedure that is used to treat compression fractures of the spine. During this procedure, bone cement is injected into the fractured vertebrae to stabilize the bone.

Kyphoplasty is a similar procedure, except that a small balloon is first inserted into the compressed vertebrae and inflated. This space is then filled with bone cement, bringing back height and stability to the vertebrae.

Both procedures can help reduce pain and restore mobility and stability. Like all medical procedures, there are risks involved with kyphoplasty and vertebroplasty Your physician will go over these with you.

Spinal Fusion

Spinal fusion is a surgical procedure in which two or more bones in the spine are fused together to prevent movement of the vertebrae and bring stability to the spine. A bone graft is used to fuse the vertebrae.

In most cases, spinal fusion is done when other options have been exhausted and when the benefits outweigh the inherent risks that come with spinal surgery.

Other Fracture Treatments

There are multiple procedures your healthcare provider may recommend for treating fractures, depending on where your fracture occurs. The goal of surgical treatment of fractures is to obtain a stable fixation, reduce pain, and permit early mobilization. Procedures may include:

• Immobilization: This is the most common treatment for simple fractures, and includes casts, splints, and braces.
• Rods, pins, screws: These may be placed to stabilize the broken bone while it heals.
• Joint replacement: This may be necessary in certain types of fracture of the hip.