Osteoporosis is primarily due to an imbalance in the bone remodeling action. Achieving optimal minerals and vitamins (through diet and supplements) is critically important even when medication is prescribed.
Several drug therapies have been approved in Canada and the U.S. for the treatment of osteoporosis. Some of the drugs are used for both prevention and treatment while others only for treatment. Follow-up bone density tests should be performed every two to three years to monitor the effectiveness of your medication and bone health program. The medication program should also be supported with calcium and vitamin supplements within a
natural treatment program.
PREVENTION AND TREATMENT
BPs are similar to natural bone material and are not hormones. They bind to existing bone and become embedded in the skeleton to create a protective layer that slows osteoclast activity from dissolving tissue on the bone's surface.
Note that long term use of bisphosphonates may increase the risk of a rare but serious fracture of the the thigh bone. (Journal of Bone and Mineral Research; October 27, 2010.) The FDA's analysis shows that using bisphosphonates for more than 3-5 years yields little benefit while carrying the risk of serious side effects.
Five bisphosphonates are available in Canada and the U.S.:
Alendronate [available as Fosamax®] Prevention doses of 5 mg daily are available as well as treatment doses of 10 mg daily or 70 mg once a week. Also available is Fosavance® which is Fosamax® with vitamin D.
Both Canada and the US have approved a less expensive generic form of Fosamax called Alendronate Sodium which is available as a 5mg tablet taken daily or a 35mg tablet taken once a week. In 2012, the FDA also approved BINOSTO™ -a once weekly, strawberry flavored effervescent tablet containing 70mg alendronate that dissolves in water. Risedronate [available as Actonel®] has been approved for post-menopausal osteoporosis at a dose of 5 mg daily. Also available is Actonel® Plus Calcium. Etidronate [available as Didronel® or Didrocal® which includes 500 mg of elemental calcium carbonate] has been approved for post-menopausal osteoporosis. It is taken on a cyclical basis, such as 400 mg for 2 weeks out of every 3 month period.Zoledronic acid [Aclasta®, known as Reclast® in the U.S.] was approved by Health Canada in 2007 for the treatment of post-menopausal women. This prescription medication is purchased by the patient and then administered by a health professional intravenously, for 15 minutes once a year.
Health Canada has issued an advisory for Aclasta- as worsening of kidney function (which may progress to kidney failure) has been reported with bisphosphonates. Doctors have been advised to measure their patients' kidney function before prescribing the drug and the drug is not recommended for patients with severe impairment in kidney function. Also, the duration of the infusion should be longer than 15 minutes.Ibandronate (Boniva, Bondronat and Bonviva) is taken as a pill once a month and has been approved as a generic medication in both Canada and the United States for post menopausal women. In 2008, the FDA issued a communication warning of the possibility of severe and sometimes incapacitating bone, joint and/or muscle pain in patients. Binosto is a once weekly, strawberry flavored, effervescent tablet containing alendronate (70mg) that dissolves in half a glass (4 oz.) of room temperature water. It has been approved in the United States for osteoporosis treatment in postmenopausal women and men and is available by prescription. It is especially attractive to people who have difficulty swallowing pills.
All of the above bisphosphonates can reduce a woman’s risk of spinal, hip and other bone fractures although Etidronate appears to be the least effective of the four drugs. Zolendronic Acid (Aclasta/Reclast) and Etidronate (Didronel®/ Didrocal®) have also been approved to assist with bone building after a
Research conducted at Leiden University, found that bisphosphonate pamidronate can still be detected in urine eight years after treatment has stopped. This may explain why osteoporotic women who have taken bisphosphonates for a long time have reduced bone mineral loss after stopping treatment.
HOW TO TAKE BPs
All BPs must be taken alone and on an empty stomach with a full glass of water. The stomach does not absorb the drugs well and the medication interacts with minerals, such as calcium, magnesium, aluminum, iron and substances in food, drink and other medications.
should not be taken at the same time as these drugs. Once-a-week Fosamax® and Actonel® tablets have now been approved for use in Canada. Research suggests that is little benefit and an
increased risk of spontaneous fractures
if bisphosphonates are taken for more than five years
COST OF BPs
The approximate yearly cost for each of these drugs in Canadian dollars is:Etidronate: $200 (both Didronel® and Didrocal®)
Alendronate (Fosamax): $500 for the 5 mg daily dose $800 for the 10mg daily doseRisedronate
: $750 for the 5mg daily dose
Medical coverage of Didrocal®, Fosamax®, Actonel® varies for each province in Canada.
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SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMs)
Selective estrogen receptor modulators (SERMs) have similar benefits to estrogen but without some of the risks associated with the hormone. These drugs behave like estrogen in some parts of the body (like the bones) but not in others (like the uterus and breasts).
Tamoxifen, the first SERM developed, has been used to prevent breast cancer for many years. Raloxifene hydrochloride (also sold as Evista®) may be recommended by your doctor if you have a family history of breast cancer in addition to bone loss. Note, however, that Raloxifene has not been tested in women who have a personal or family history of breast cancer.
Raloxifene/Evista has been shown to maintain bone density in the spine, hip and other bones. Possible side effects include:
- hot flashes or night sweats
- leg cramps
- muscle and joint aches
- weight gain
- vaginal dryness
These effects may occur within the first three to six months of therapy and some of them may lessen over time. Rare but serious side effects include blood clots in the deep veins, called deep vein thrombosis (DVT), a risk also associated with estrogen therapy. Raloxifene should therefore be used with caution for women who are at risk for blood clots.
HOW TO TAKE RALOXIFENE
Raloxifene may be taken with or without food at any time of the day. However, it is best to take the medication at the same time each day so that it becomes part of your daily routine. It should be halted if you expect a prolonged period of immobility due to surgery or an illness.
can cost over $800 annually or approximately $500 if the generic version is purchased on-line. Health coverage varies across Canada.
Most osteoporosis medication can be purchased on-line at a competitive price with a doctor's prescription.
TREATMENT OF OSTEOPOROSIS
BONE METABOLISM REGULATOR (Denosumab, Prolia™)
Denosumab is a new class of osteoporosis treatment that inhibits the development and activation of osteoclasts (the cells that eat away bone). It reduces the risk of fractures at the spine, hip and other sites in women with postmenopausal osteoporosis. It is administered as an injection (60 mg/mL solution) twice yearly.
Side Effects may include pain in the muscles, arms, legs or back and a skin condition with itching, redness and/or dryness. It also slightly increases the risk of cellulitis, a skin infection treated with antibiotics. In rare cases, osteonecrosis of the jaw has been reported in patients treated with denosumab.
CALCITONIN NASAL SPRAY
Calcitonin nasal spray, available in Canada as Miacalcin®, is approved for the treatment of osteoporosis in women who have been postmenopausal for at least five years.
Calcitonin injection is not currently approved for the treatment of osteoporosis but is sometimes prescribed for people who have fractures of the vertebrae, mainly to relieve pain.
The following medications are not approved for the treatment of osteoporosis in Canada but may be prescribed in specific circumstances.
CALCITRIOL (Vitamin D Metabolite)
Calcitriol (Rocaltrol®) is the "active" form of vitamin D which helps the intestines absorb calcium. It may be prescribed for individuals in whom normal metabolism of vitamin D is disrupted, eg. with kidney disease.
LOW-DOSE ORAL CONTRACEPTIVE (the Pill)
A low-dose oral contraceptive may be recommended for young women who have low bone density and women over 35 who are in the transitional period leading up to menopause- when there is a 1% annual loss of bone mass as estrogen levels decrease.
Testosterone replacement (in the form of injections or pills) have traditionally been prescribed to men diagnosed with osteoporosis. Fortunately, testosterone patches are now available-which is a great relief to all the men who have been giving themselves injections with a 22g needle during the past years.
Parathyroid hormone (PTH) has been approved for use in the United States and Canada for the treatment of severe osteoporosis.
Daily infusions or injections of synthetic PTH (called teriparatide or Forteo®) can slow bone loss and increase bone mass by up to 20 percent in the first year of treatment. PTH is more potent than bisphosphonates and is typically prescribed for women who have had a fracture or are at high risk of having one. Because this medication was only recently approved, its long-term effects are unknown.
In research studies, this medication was shown to cause bone cancer in lab rats. Although no bone tumors have been reported in humans taking PTH-because of the potential risk it should not be used to prevent or treat mild osteoporosis.
There is general agreement on the selection of calcium and vitamins that should be included in a
natural treatment program for osteoporosis.
is a dual-action agent that has been shown to increase bone density 8%-14% over a three year period.
Strontium may be purchased for approximately $90 USD
annually and must be taken with calcium and vitamin D supplements.
In addition to strontium and a program of inexpensive supplements,the following remedies are recommended by some practitioners:
Bio-identical hormones are identical in structure to the hormones found in our own body and are now widely available from compounding pharmacies with a prescription from a naturopathic doctor. These pharmacies create patients’ prescriptions from the original active drugs rather than dispensing pre-made pills.
There are no large studies to prove the effectiveness of these hormones but a number of small studies suggest that bio-identical hormones have the same beneficial effects as the conventional HRT with less risk.
TAKE YOUR MEDS!
A National Osteoporosis Society report titled “The real facts of life in osteoporosis” states that 77% of patients taking a daily bisphosphonate stop taking their medication within a year...as do almost two-thirds of patients taking bisphosphonates once a week. Compared with non-adherent patients with osteoporosis, adherent patients have a reduction in fracture rates of 16 to 23%.
Calcium and vitamin supplements
will help to reinforce the benefits of any osteoporosis medication and are encouraged by most doctors and health professionals.
To learn about calcium and vitamin supplements that support osteoporosis medication....visit Osteoporosis Treatment Guidelines.
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