Content provided by the Faculty of the Harvard Medical School

By the way, doctor: What can I take for osteoporosis besides Fosamax?

By the way, doctor

What can I take for osteoporosis besides Fosamax?

Q. I'm 60 and have osteoporosis. My doctor is recommending Fosamax, but I'm concerned about jawbone problems. Are there any other drugs I can take?

A. Many are asking the same question because of the publicity surrounding a small number of women who've suffered the death of jawbone tissue (osteonecrosis of the jaw) while taking medications in the same class as Fosamax (alendronate). Statistically speaking, the risk is small — less than 1 in 100,000 — but it is genuine, and there are some alternatives.

Fosamax is one of a group of drugs called bisphosphonates that are regarded as first-line medications for preventing and treating osteoporosis. Most of the jawbone problems associated with these drugs have occurred in cancer patients receiving intravenous injections of zoledronate (Zometa) or pamidronate (Aredia) for bone pain. Experts don't know why these patients seem particularly vulnerable, but it may be that cancer treatment changes their response to bisphosphonate therapy. Also, the doses needed to treat bone pain are higher than those required for preventing or treating osteoporosis.

Other bisphosphonates include risedronate (Actonel) and ibandronate (Boniva). Fosamax and Actonel are taken orally, either once a day or once weekly. Boniva comes as a monthly pill or can be taken intravenously every three months. Bisphosphonates slow bone loss and have been shown to reduce fracture risk. But some women can't tolerate the side effects — chiefly heartburn and esophagitis (irritation of the esophagus) with oral bisphosphonates, and muscle aches with both oral and intravenous preparations. For these women and anyone worried about bisphosphonates, there are alternatives, each with its own benefits — and side effects.

Hormone therapy (estrogen with or without a progestin) is FDA-approved for preventing and treating osteoporosis. In the Women's Health Initiative, women taking hormone therapy had a reduced risk for spine and hip fractures. But this benefit wasn't considered worth the attendant increase in risk for breast cancer, cardiovascular disease, and blood clots. Because of these risks, hormone therapy is no longer considered a first-line osteoporosis treatment, but it's still prescribed for women who can't tolerate the other drugs.

Raloxifene (Evista) is another possibility. A first-line drug for osteoporosis prevention and treatment, raloxifene is a selective estrogen receptor modulator (SERM), meaning that it acts like estrogen in some tissues but not in others. For example, it acts like estrogen in bone but not in breast tissue, so it counters bone loss without increasing breast cancer risk. However, like estrogen, it increases the risk for blood clots, and unlike estrogen, it can exacerbate hot flashes.

Calcitonin is a naturally occurring hormone involved in bone metabolism. Though not as potent as bisphosphonates, it slows bone loss and increases bone density in the spine in women who are at least five years past menopause. Calcitonin can be taken as an injection or a nasal spray. The injectable form can cause flushing of the face and hands, nausea, and rash. The only side effect of the nasal form is a runny, irritated nose.

Parathyroid hormone (PTH) is made by the parathyroid glands, small organs embedded in the thyroid gland. An injectable form of PTH, teriparatide (Forteo), can be given intermittently to reduce fracture risk. All of the osteoporosis medications reduce bone loss; only Forteo actually builds bone. But it's expensive and, in animal studies, has been shown to increase the risk of osteosarcoma (bone tumors). Consequently, Forteo is recommended only for people with severe osteoporosis who are at risk for fractures and haven't responded to bisphosphonates.

There are several nondrug ways to preserve healthy bone mass. Be sure to get 1,200–1,500 milligrams of calcium (from diet or supplements) and at least 400–800 IU of vitamin D every day. Engage in moderate-intensity physical activity several times a week, including weight-bearing exercise (such as brisk walking) and resistance training (using free weights). And avoid smoking, actively or passively. Keep in mind that bone mineral density is not the only influence on your risk of having a fracture. Strong muscles and good flexibility will help improve balance and reduce the likelihood of a bone-breaking fall. An activity such as tai chi is an excellent balance-booster.

— Celeste Robb-Nicholson, M.D Editor in Chief, Harvard Women's Health Watch

Last updated:	September 05, 2008