Bone Health: The Ins and Outs of Osteoporosis Medications
With many drugs on the market and long-term studies showing their varied effects, picking the right treatment can be tough. Local doctors weigh in on which drug may be right for you.
Confused and concerned about calcium, bone health and osteoporosis medications like Fosamax, Prolia and Boniva?
“It’s the number one thing that my post-menopausal patients are asking me about,” says Dr. Christine Ellis, an OB/GYN with Associates for Women’s Medicine in West Chester and Exton. “There’s a lot of information out there, but not all of it is correct.”
Every patient’s needs are different, but one thing’s for sure: “We’re looking at a huge population of baby boomers and their parents who are dealing with osteoporosis,” says Dr. Gary Gordon, chief of rheumatology at Lankenau Hospital.
The National Osteoporosis Foundation reports that 10 million Americans have the disease and 34 million may develop it. Both men and women are at risk. The NOF estimates that, of people older than 50, half of all women and one in four men will break a bone because of osteoporosis.
In layman’s terms, bones are made of calcium phosphate, collagen and cells that slough away old cells and replace them with new ones. This process happens with human bodies of every age and both genders. But, as we age, the regeneration-replacement process slows, resulting in less dense, more fragile bones.
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That slowing is exacerbated in post-menopausal women because of their estrogen loss, which depletes bones of that hormone’s calcium absorption benefits. How much the bones are affected depends on how strong they were to begin with, which is why doctors firmly recommend prevention as the first wave of treatment. But one of the problems with prevention is that people are not getting sufficient amounts of calcium.
In 2011, the National Academies’ Food and Nutrition Board issued its recommended daily allowances for calcium: 1,000 mg for all adults 19-50, plus an increase to 1,200 mg when women turn 51, and an increase to 1,200 mg when men hit 71. According to the USDA, eight ounces of plain, low-fat yogurt has 415 mg of calcium, one cup of cottage cheese has 138 mg of calcium and a half-cup of broccoli has 21 mg of calcium. Together, that equals only half of the RDA for calcium for women ages 19-50.
That’s why supplements are called for. But recent studies show that calcium supplements might have harmful effects. Two long-term studies—one by the University of Auckland and one from the European Prospective Investigation Into Cancer and Nutrition—report higher rates of heart attack in people who took calcium supplements.
“It’s not how much calcium a person takes, it’s what they absorb,” says Mark Stayton, sales manager at Martindale’s Natural Market in Springfield.
And to absorb calcium, you need vitamin D and magnesium. “That’s how the calcium gets delivered to the bone cells,” says Stayton. “Without D and magnesium, you have elemental calcium in your body that isn’t utilized. The body could eliminate it or it might end up as plaque in your arteries.”
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Ellis and Gordon confirm Stayton’s analysis. “But when taken properly, calcium can go a long way toward preventing osteoporosis,” says Ellis. “And the problem with osteoporosis is that it’s treatable, but not reversible. That’s when we need osteoporosis medications.”
Fosamax, Boniva, Reclast and Actonel are bisphosphonates; Forteo is a parathyroid hormone; and Prolia is a RANK ligand inhibitor. The purpose of all the drugs is the same: to manipulate the regeneration-replacement cycle of bone cells. The medications do that in basically the same ways—although some are stronger than others, Gordon says.
While ads featuring Sally Field and Blythe Danner promote the bimonthly or monthly medications as easier to take than daily Fosamax, they also can have side effects. Those side effects—including femur fractures and breakages in other bones—have caused concern among post-menopausal women.
For many, the side effects may have been exacerbated. “When the drugs were introduced, we were misled by the drug companies and told to treat everyone with osteopenia—and right away, before it advanced to osteoporosis,” Gordon says. “As a result, people have been on these medications for longer than perhaps they need to be, so some of the side effects may be more pronounced.”
Evidence of that is slowly becoming public. In May of this year, the Food and Drug Administration issued an analysis of bisphosphonates, suggesting—but not mandating—that patients should be on the medications for no more than five years. That comes as an unwelcome shock to patients who’ve been on Fosamax for up to 10 years, Ellis says.
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And her practice has made changes. “We reevaluated who was really at risk,” she says. “Certainly, that was done on a case-by-case basis. But we no longer suggest that everyone with osteopenia goes on osteoporosis medication.”
Which medication remains an issue. Ellis still prescribes Fosamax for her patients. She believes the drug’s benefits outweigh the risks, which happen in an extremely low percentage of the population. She only prescribes Prolia, Boniva, Reclast and Actonel for patients who’ve already had a bone fracture, those who cannot tolerate Fosamax because they have acid reflux issues, and patients suffer from dementia or a physical disability that makes them unable to take the tablet every morning.
“In patients who need osteoporosis medication, I go to Fosamax first,” she says. “We don’t have any long-term studies of the other medications, either.”
Gordon stopped prescribing Fosamax four years ago. He most commonly turns to Actonel.
Doctors do agree on one thing: Prevention is the best form of treatment for osteoporosis. “Get enough calcium in your younger years, and maybe you won’t be having this conversation with me at all,” says Ellis.