Medically Reviewed by Dr. Tashiya Mirando, MD, Written by Nabiha Khalid, Medical Writer
Osteoporosis is often called a “silent disease” because people usually do not experience noticeable symptoms until a bone breaks or a screening reveals lower-than-normal bone density. In osteoporosis, the body does not produce enough new bone or loses bone faster than it can be replaced. As a result, bones weaken and become more susceptible to fractures. Research shows this condition can remain undetected until a fracture occurs or a dedicated bone density test is conducted.
While menopause hormone therapy (MHT) with estrogen (alone or with progestogen) is a proven way to reduce fracture risks, some individuals may need alternative treatment approaches. Several medical treatments can help prevent or manage osteoporosis. These treatments work to make bones stronger, prevent additional bone loss, and decrease chances of fractures. This article explores the major categories of non-hormonal medications—sometimes called “non-hormone” treatments—that can help strengthen bones, prevent further bone loss, and reduce the risk of fractures.
Categories of Osteoporosis Medications
When it comes to fighting osteoporosis, menopause hormone therapy isn’t the only answer. From cutting-edge bone-building drugs to time-tested medications that prevent bone loss, today’s medical arsenal offers diverse options for those seeking non-hormonal treatments to protect their bone health and prevent fractures.
Osteoporosis treatments generally fall into two broad groups:
- Anti-remodeling drugs: These work by slowing down the rate at which bone is broken down.
- Osteoanabolic (bone-building) therapies: These work by stimulating new bone formation.
Either approach can strengthen bones and lower fracture risk.
1. Anti-Remodeling Drugs
Anti-remodeling medications slow down the rate at which bones are broken down, helping to preserve bone mass and lower fracture risk. Below, we discuss three key options—bisphosphonates, denosumab, and calcitonin salmon—and examine how each can contribute to effective osteoporosis management.
A. Bisphosphonates
Common examples: Alendronate, Risedronate, Ibandronate, Zoledronate
Bisphosphonates are some of the most commonly prescribed medications for osteoporosis. They have been approved for both prevention and treatment of postmenopausal osteoporosis. Taken either orally (daily, weekly, or monthly) or via intravenous (IV) infusion (every 12 to 24 months in the case of Zoledronic acid), bisphosphonates can improve bone density by 4% to 10% over three years and reduce the chance of spine, hip, and other fractures. However, they do not repair damaged bone structure.
Effectiveness of Bisphosphonates:
- Risedronate and Zoledronate: Reduce vertebral, non-vertebral, and hip fracture risks.
- Alendronate: Reduces vertebral and hip fracture risks.
- Ibandronate: Primarily reduces vertebral fracture risks.
Side Effects of Bisphosphonates:
- Oral bisphosphonates can cause stomach irritation and, in some cases, muscle or bone pain.
- IV forms (such as Zoledronic acid) may cause flu-like symptoms, especially after the first dose.
- Caution is advised for individuals with severely impaired renal function.
- In rare instances, a condition called osteonecrosis of the jaw (impaired healing of the jawbone especially after dental procedures like implants or extractions) has been linked to bisphosphonate use. Good dental care before procedures and preventing infection lowers risk of osteonecrosis, and maintaining good dental health helps reduce this risk.
While very rare, unusual fractures become a small risk with long-term use—especially after 8 to 10 years. The rate is around 1 in every 1,000 patients who use bisphosphonates for that length of time. Consequently, many clinicians recommend a “bisphosphonate holiday”, i.e., after 3 to 5 years, for women at lower risk of fracture. Those at higher risk may switch to a different therapy.
B. Denosumab
Denosumab is given by injection every 6 months to slow down bone breakdown, thereby reducing the fracture risk (vertebral, non-vertebral, and hip).
In postmenopausal women with osteoporosis, 3 years of denosumab treatment lowered the incidence of vertebral fractures by 68% and hip fractures by 40%.
Side Effects:
- Denosumab may carry a slightly increased risk of unusual fractures with long-term use.
- Some individuals report a higher frequency of skin rash and infection, though large studies up to 10 years have not shown a major increase in severe infections or immune-related issues.
- More research is ongoing to clarify the relationship between the duration of denosumab therapy and the risk of potential adverse effects.
Therefore, while Denosumab remains an effective treatment option for osteoporosis, healthcare providers should carefully monitor patients during long-term use and weigh the demonstrated benefits against potential risks when developing individualized treatment plans.
C. Calcitonin Salmon (Nasal Spray)
Calcitonin salmon spray is generally a last resort, recommended only for individuals who cannot tolerate other osteoporosis therapies. Research shows it has less pronounced effects on bone density and may be associated with a small increase in vertebral fracture risk. Studies have also shown that it does not prevent bone loss in early postmenopausal women.
Some evidence also suggests a potential link with elevated cancer risk, although further investigation is needed to confirm this association. Side effects can include nasal irritation and back pain.
2. Osteoanabolic (Bone-Building) Therapies
In contrast to anti-remodeling drugs, osteoanabolic therapies specifically enhance bone formation and help rebuild the bone architecture. They can significantly increase bone density and may reduce fracture risk more effectively than anti-remodeling agents. These therapies are typically recommended for women with osteoporosis who are at a very high risk of fractures.
Treatment with osteoanabolic drugs is usually limited to 12 to 24 months. Once therapy is stopped, bone mineral density may decline quickly. Therefore, a follow-up medication (often an anti-remodeling drug) is typically prescribed to preserve the gains achieved.
A. Parathyroid Hormone Receptor Agonists
Parathyroid hormone receptor agonists work by activating osteoblasts—cells that build new bone. This targeted stimulation can significantly enhance bone density and reduce fracture risk, making these therapies a valuable option for individuals with more severe osteoporosis.
1. Teriparatide
- A synthetic form of parathyroid hormone (PTH) that promotes new bone growth by stimulating bone-building cells (osteoblasts).
- Clinical trials show a 74% reduction in vertebral fracture risk and a 39% reduction in non-vertebral fractures compared with placebo.
- Given as a once-daily injection under the skin, it is followed by an anti-remodeling medication to maintain the benefit.
Note: You need to keep using antiresorptive therapy after teriparatide treatment to maintain its benefits.
2. Abaloparatide
- Similar mechanism to teriparatide, given by daily injection under the skin.
- Compared with placebo, it reduced new vertebral fractures by 86% and nonvertebral fractures by 43% over 19 months in postmenopausal women.
Parathyroid hormone receptor agonists like teriparatide and abaloparatide offer a powerful approach to rebuilding bone and reducing fracture risk, particularly for those with severe osteoporosis, when combined with ongoing antiresorptive therapy.
B. Romosozumab
Romosozumab works by blocking a protein called sclerostin, thus promoting bone formation and reducing bone breakdown simultaneously. Studies show it lowers vertebral and non-vertebral fracture risks in postmenopausal women. Romosozumab is administered as 2 monthly injections for up to one year and is typically prescribed with the same considerations as teriparatide.
[Safety Note: Romosozumab is not recommended for individuals with a high risk of cardiovascular events, especially those who have experienced a recent heart attack or stroke.]
Key Takeaways
For those unable or unwilling to use menopause hormone therapy for osteoporosis, a variety of non-hormonal treatments can help strengthen bone and decrease fracture risk. From anti-remodeling medications, such as bisphosphonates and denosumab, to osteoanabolic agents like teriparatide, abaloparatide, and romosozumab, multiple pathways exist to manage this “silent disease.”
Each medication has its own safety profile, benefits, and limitations, so it is critical to discuss these options with a healthcare professional to identify the most appropriate treatment approach.
References
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