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Osteoporosis is a predictable complication of dozens of commonly prescribed medications. Here are 10 classes of medications that sometimes devastate bone density. If you have to take these drugs, then you have to take steps to prevent osteoporosis.

Osteoporosis is a complication of over 100 prescription medications that can accelerate the destruction of bone or interfere with its growth. It may not be possible to avoid these drugs, but at least it is possible to be on the lookout for the earliest stages of osteoporosis to avoid bone fractures and breaks. Here are 10 types of medications that engender brittle bones. 

1. Steroids

Steroids, also referred to as glucocorticoids, accelerate the activity of the osteoclasts that break down old bone but slow down the activity of the osteoblasts that build new bone to replace it. Many people who take long-term steroid treatment for various conditions of inflammation such as rheumatoid arthritis and asthma find that bone fractures follow. The increased risk of fractures persists for two years after steroids are discontinued. If control of inflammation is not possible with lower doses of steroids, then the doctor will usually prescribe an alternative medication to decrease the activity of the immune system.

Examples of steroid drugs that can cause osteoporosis:

Asthma drugs such as Asthma drugs such as beclomethasone dipropionate (Qvar), budesonide (Pulmicort), budesonide/formoterol (Symbicort) — a combination of a steroid and a long-acting bronchodilator drug, fluticasone (Flovent),  fluticasone inhalable powder (Arnuity Ellipta), fluticasone/salmeterol (Advair) — another combination of a steroid and a bronchodilator, mometasone (Asmanex), and mometasone/formoterol (Dulera) –— yet another combination a steroid and a bronchodilator.

Rheumatoid arthritis drugs such as  betamethasone, dexamethasone (Decadron), dexamethasone (Dexpak Taperpak, Decadron, Hexadrol), hydrocortisone (Cortef, A-Hydrocort), methylprednisolone (Depo-Medrol, Medrol, Methacort, Depopred, Predacorten), prednisolone, prednisone (Deltasone, Sterapred, Liquid Pred), triamcinolone.

2. Proton pump inhibitors

Proton pump inhibitors decrease the absorption of calcium. People who are already diagnosed with osteoporosis and receiving treatment with bisphosphonates should not take them. Anyone who takes drugs in the proton pump inhibitor class should take supplemental calcium, vitamin D, magnesium, and vitamin K2, and continue taking them for at least a year after the proton pump inhibitor is discontinued.

Examples of proton pump inhibitors that can cause osteoporosis include:

Aspirin and omeprazole (Yosprala), dexlansoprazole (Dexilent, Dexilent Solutab), esomeprazole (Nexium, Nexium IV, Nexium 24 HR), esomeprazole magnesium/naproxen (Vimovo), lansoprazole (Prevacid, Prevacid IV, Prevacid 24-Hour), omeprazole (Prilosec, Prilosec OTC), omeprazole/sodium bicarbonate (Zegerid, Zegerid OTC), pantoprazole (Protonix), rabeprazole (Aciphex, Aciphex Sprinkle).

3. Seizure medications

Many of the older seizure medications seem to interfere with the body’s use of calcium. People who have other risk factors for osteoporosis may have to be treated with newer medications for epilepsy such as levetiracetam.

Examples of seizure medications that can cause osteoporosis include:

Valproic acid (Depakote, Depakene)

4. Medroxyprogesterone acetate (MPA) 

This common birth control pill reduces estrogen levels, which in turn increases the rate at which old bone is recycled but not the rate at which new bone is produced. When women go off this form of contraception it takes about two years of supplementation with at least calcium, vitamin D, magnesium, and vitamin K2 to recover bone loss in the spine and hips. Oral contraceptives don’t cause this problem.

Examples of brands of medroxyprogesterone acetate that can cause osteoporosis include:

Depo-Provera

5. Aromatase inhibitors

Medications to reduce estrogen production, such as tamoxifen for estrogen-receptor positive breast cancer, accelerate the destruction of bone. Although taking bone health supplements is a good idea, it is not enough. Usually the doctor will also have to prescribe bisphosphonates or other medications to minimize bone damage during cancer treatment.

Examples of aromatase inhibitors that have the side effect of causing osteoporosis include:

Anastrozole (Arimidex), exemestane (Aromasin), and letrozole (Femara).

6. GnRH agonists

These drugs for treating prostate cancer reduce the production of follicle stimulating hormone (FHS) and luteinizing hormone (LH) in the testes. Reducing FHS and LH, in turn, reduces the production of testosterone, depriving the cancer of a hormonal stimulant, but also deprives the man’s body of the tiny amount of estrogen it makes from testosterone. It’s usually necessary to “pre-treat” osteoporosis with bisphosphonates, denosumab, raloxifene, or toremifene when men with prostate cancer receive these treatments. If the bone damage caused by cancer treatment is more of problem than the bone damage caused by metastatic cancer itself, the oncologist may prescribe other cancer treatments.

Examples of the most commonly used GnRH agonists that often have the complication of osteoporosis include:

Goserelin acetate (Goserelin), Leuprolide acetate (Lupron).

7. Selective serotonin reuptake inhibitors (SSRIs)

Antidepressants in the selective serotonin reuptake inhibitor (SSRI) class are associated with increased risk of osteoporosis, although researchers do not yet know what the connection really is. People who need treatment for depression who have risk factors for osteoporosis usually can be treated with other antidepressants.

Examples of selective serotonin inhibitors that may increase the risk of osteoporosis include:

Citalopram (Celexa, Cipramil), escitalopram (Lexapro, Cipralex), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox, Faverin), paroxetine (Paxil, Seroxat), sertraline (Zoloft, Lustral).

8. Thiazolidinediones (also known as TZDs)

These largely abandoned medications for diabetes have the distressing side effect of causing stem cells that the body intends to use make bone cells into stem cells that the body uses to make fat cells. Long term use of these drugs can lead to fat deposits inside bone. Fat weakens bone. It is unusual for people to get TZDs, and any diabetic who does should ask about alternative medications.

Examples of TZDs still on the market that may cause osteoporosis include:

Pioglitazone (Actos), rosiglitazone (Avandia).

9. Coumadin (warfarin)

Coumadin (which is the brand name for the blood-thinning drug warfarin) is associated with decreased mineral deposition in bone. The problem is not that the drug increases the breakdown of old bone or decreases the production of new bone, but that it is necessary to reduce consumption of vitamin K to use the medication reliably. If possible, the doctor may prescribe a newer blood thinner. If the blood problem has to be treated with Coumadin, then it may be necessary to take bisphosphonates, and supplemental calcium, magnesium, and vitamin D. Vitamin K1, the form of vitamin K that is found in leafy green interferes with the drug. It is important to avoid vitamin K1. Vitamin K2, the kind of vitamin K that helps to regulate calcium transport, does not interfere with Coumadin and can be used to increase bone health. Just be sure to avoid K1 when you get K2.

Brand names of warfarin include:

Coumadin. (Coumadin is the brand name. Warfarin is the pharmacological name. They are the same drug.)

10. Heparin and related drugs

Heparin and biologically similar anticoagulants are given to patients in hospitals to prevent blood clots. Long-term use of heparin may almost completely stop the formation of new bone while it accelerates the destruction of old bone. If it is necessary to give heparin for an extended period, the hospitalist may prescribe Fondaparinux.

Examples of heparin-like blood thinners that may cause osteoporosis if used long-term include:

Dalterpain (Fragmin), enoxaparin (Lovenox), heparin (Heparin Sodium), tinzaparin (Innohep).

People required use any of these medications may need to take drugs to prevent destruction of bone. The problem in this situation is that patients don’t have any symptoms yet, but the medications to prevent bone loss usually have some disagreeable side effects. It’s important to take osteoporosis drugs despite their side effects to avoid broken bones and even greater problems that presented by the first disease.

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  • Hardy RS, Zhou H, Seibel MJ, Cooper MS. Glucocorticoids and Bone: Consequences of Endogenous and Exogenous Excess and Replacement Therapy. Endocr Rev. 2018 Oct 1.39(5):519-548. doi: 10.1210/er.2018-00097. Review. PMID: 29905835.
  • Nguyen KD, Bagheri B, Bagheri H. Drug-induced bone loss: a major safety concern in Europe. Expert Opin Drug Saf. 2018 Oct.17(10):1005-1014. doi: 10.1080/14740338.2018.1524868. Epub 2018 Sep 23. Review. PMID: 3022236.
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