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What's the most important overlooked fact about medications for osteoporosis? People have to take their meds for them to work! Here are some helpful hints to keep you on track withthe most important pharmaceutical treatments for osteoporosis.

There is no "magic bullet" for osteoporosis. No single medication stands out above all the rest. Every treatment has benefits and side effects. But to prevent painful fractures of the hips, spine, and other bones, you have to stick with your program. Here are 10 hints for staying on track.

1. Take nutritional supplements every day

Calcium needs magnesium and vitamin D to be absorbed. It doesn't help to take your calcium and skip your D or magnesium. And if you are at risk for cardiovascular disease, you really need to take vitamin K2, every day. Don't take nutritional supplements on a weekly, monthly, or WIFL (whatever I feel like) schedule. Take them every day.

2. Don't even bother taking calcium if you aren't going to take other supplements with it

It doesn't do any good to take just calcium supplements. Your body can't use them without vitamin D, magnesium, and vitamin K2. Take all of your supplements every day.

3. If you are a woman taking a bisphosphonate, ask your doctor about adding Menostar or Evista

Bisphosphonates can have some unpleasant side effects. We won't go through them now, because if you're taking them, you already know what the problems are. It takes some determination to finish your bisphosphonate medications. But as long as you are putting up with side effects, why not add two more drugs to get added bone strength? Menostar (an estrogen patch, for use by women) and Evista (raloxifene, a compound that isn't estrogen but that acts like estrogen in bone) often add more minerals to bone than just taking bisphosphonates without estrogen. 

4. If you are taking Forteo (teriparatide), ask about PREOS

Doctors are always trying to get us to take the latest and greatest drugs, and insurance companies are always telling us they won't pay for them. However, if you are getting treated with a drug called Forteo, ask you doctor if you might not do better on a medication called PREOS. It's another synthetic form of parathyroid hormone. Your doctor will have read the latest studies on both drugs, and will be able to advise you on whether PREOS will work better for you. The maker of PREOS designs all of its drugs so that they work better together (to encourage you to get all of your medications from them), so if you take other medications made by AstraZeneca, you may do better on this medication, with fewer side effects.

5. And if you are going to need to come off Forteo soon, ask about Tymlos

Forteo isn't a medication that works forever. After about two years, side effects begin to exceed benefits, and it is necessary to take something else. One possibility is Tymlos. Its clinical testing discovered that it "reduces the relative risk of new vertebral fractures by 86 percent and also lessens the chance of nonvertebral fractures by 43 percent." That really means that the average user of the drug has an absolute risk reduction of vertebral fractures of about two percent, since they are not especially likely with treatment, but that may be a benefit you wish to pursue.

The price of Forteo is going up nine to 15 percent a year. In the USA, that means that uninsured patients would pay $19,500 per year. However, the price of Forteo and Tymlos to your insurance company are converging so that your out of pocket expense may be the same.

6. If you already have fractures of the spine, consider taking Miacalcin

Miacalcin is a thyroid hormone that balances the effects of  parathyroid hormone. It keeps calcium levels in the bloodstream from going too high, and it helps the kidneys excrete excess calcium. It usually increases bone density in the spine and reduces back pain.

7. Having dental surgery and take Aredia or Zometa? Ask your doctor about taking a vacation from bisphosphonates

Two bisphosphonate medications carry a small risk of a catastrophic complication in the jawbone if they are used after dental surgery. If you take Aredia (pamidronate) or Zometa (zoledronic acid), be sure to let both your doctor and your dentist know well in advance of the procedure.

8. If you are on any kind of estrogen replacement therapy, ask about Menostar

This estrogen patch may cause fewer side effects than other forms of estrogen replacement.

9. Your doctor should start you on bisphosphonates like Actomel or Fosamax, and then try medications like Forteo (teriparatide) and Prolia (denosumab)

It's unusual for the doctor to skip to the newer, more expensive osteoporosis medications without giving bisphosphonates a try. It might even be a good idea to get a polite, discreet second opinion if your doctor does not give bisphosphonates after your diagnosis. Of course, if you have already received bisphosphonates from another doctor and your bone mineral density has not improved, then the second-line medications may be appropriate.

10. As a general rule, just say no to steroid drugs

Glucocorticoids like prednisone are extremely problematic for people who have osteoporosis. There may be situations in which it is impossible to avoid them (for example, you have to be given a drug to which you are mildly allergic during surgery), but always ask about alternatives when your doctor orders them and make sure every doctor who prescribes for you knows you have osteoporosis.

  • Body JJ, Bergmann P, Boonen S, et al. Non-pharmacological management of osteoporosis: a consensus of the Belgian Bone Club. Osteoporos Int. 2011. 22(11):2769–2788.
  • Cohen A, Fleischer J, Freeby MJ, McMahon DJ, Irani D, Shane E. Clinical characteristics and medication use among premenopausal women with osteoporosis and low BMD: the experience of an osteoporosis referral center. J Womens Health (Larchmt). 2009. 18(1):79–84.
  • Miller P, Hattersley G, Riis B J. “Effect of Abaloparatide vs Placebo in New Vertebral Fractures in Postmenopausal Women With Osteoporosis: A Randomized Clinical Trial” JAMA 2016. 316(7): 722-733. doi:10.1001/jama.2016.11136/
  • Photo courtesy of SteadyHealth

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