Therapeutic options for osteoporosis include medications as well as calcium and vitamin D and exercise. Calcium and vitamin D alone is not enough in women after menopause or for some men. Various types of medications are available, and each one increases BMD and reduces fracture risk, some to a different degree than others. All medical treatments for osteoporosis to date are anti-resorptives, except for Forteo* (Teriparatide), which is an anabolic agent.

Anti-resorptive osteoporosis therapies decrease bone loss and decrease bone turnover, some more strongly than others. They all increase bone density and reduce the risk of breaking a bone, but how long to use these stronger, longer acting medications has become an important question over the last few years. The most commonly prescribed anti-resorptives are the 'bisphosphonates' which include: Fosamax, Actonel, Atelvia, Boniva and Reclast. Prolia is also a strong anti-resorptive, but it is reversible over a 6 months period of time, where the bisphosphonates when stopped are still somewhat effective in preventing bone loss for months or years later. Prolia reduces bone loss for only 6 months after an injection and is not effective after this period of time, so if osteoporosis treatment is still needed, another Prolia injection or a different treatment would be necessary.

A summary regarding long-term treatment with bisphosphonates is provided from the Endocrine Society, 'Endocrine Society Statement on Bisphosphonate Use for Treatment of Osteoporosis' and key points from Dr. Black include:

  1. Patients with bone density T-scores of -2.5 or lower at the femoral neck after 3 to 5 years of treatment are at the highest risk for vertebral fractures and appear to benefit most from continuation of bisphosphonates.
  2. Patients with an existing vertebral fracture and T-scores up to -2.0 may also benefit from continued therapy.
  3. Patients with femoral neck T-scores above -2.0 have low risk of vertebral fractures and are unlikely to benefit from continued treatment after 3-5 years.

Black D.M., Bauer D.C., Schwartz A.V., Cummings S.R., Rosen C.J. 10.1056/NEJMp1202623

FDA approved therapies for prevention and/or treatment of osteoporosis

  • Fosamax "Alendronate" (oral 70mg once a week) with or without vitamin D 2800IU or 5600IU (Generic Alendronate has been available now since Feb 2008 but does not have vitamin D in it)
  • Actonel "Risedronate" (oral 35mg once a week in am with a 30 minutes wait after dosing) or (150mg once a month in am with a 30 minutes wait after dosing) or better yet, now Atelvia, also "Risedronate", but dosing is AFTER breakfast (oral one tablet 35mg once a week, no waiting)
  • Boniva "Ibandronate" (oral 150mg once a month waiting an hour after dosing or 3mg intravenous over 30-60 seconds every 3 months)
  • Evista "Raloxifene" (oral daily anytime)
  • Miacalcin "Calcitonin" (nasal spray daily)
  • Forteo* "Teriparatide" or Parathyroid Hormone (subcutaneous injection daily for 2 years)
  • Reclast "Zoledronic Acid" (5mg intravenous over 15-30 minutes once a year)
  • Prolia "Denosumab" (60mg subcutaneous injection twice a year)

*Forteo is parathyroid hormone, the first bone forming, anabolic, agent that stimulates 'osteoblasts', the cells making bone. It is taken as a daily subcutaneous injection for 2 years and is FDA approved for men and women with osteoporosis and for steroid-induced osteoporosis treatment as well.

Forteo is expensive and has a Box warning regarding osteosarcoma. Teaching sessions for Forteo are held once or twice a month at our downtown office and are given by a nurse practitioner sponsored by Eli Lilly & Co., the pharmaceutical company that manufacturers Forteo. Patients for the Forteo sessions are asked to first check-in in our office, though the meeting is free and held in a class room close by. Patients are often scheduled to see Dr Kohlmeier the same day. The Forteo teaching sessions give you more information about Forteo's Box warning and other important facts you need to know before starting Forteo.

It is always important to discuss which medical therapy is best for you with your primary care provider as well as with Dr Kohlmeier. Before starting medical therapy, blood and urine tests (24 hour collection) may help determine why your bone density is low or why you have an increased fracture risk. These tests will look for hormone or calcium abnormalities as well as vitamin D deficiency for example, many of which can be reversed once discovered.

Sixty percent of men with osteoporosis and as many as 50% of women with osteoporosis have a silent reason for bone loss called a Secondary Cause of Bone Loss. If untreated, medication for osteoporosis may not be as effective in increasing BMD or bone strength and reducing fracture.