Osteopenia Medications and Treatment

If you've been diagnosed with osteopenia (low bone density), your healthcare provider may have recommended treatment. This might include a prescription drug, such as a bisphosphonate, to help slow bone loss and prevent osteoporosis. It might also involve a vitamin D supplement if you are deficient, as well as lifestyle changes to reduce your risk of injury.

Whether or not to treat osteopenia with drugs is controversial, particularly in people who have not had a fragility fracture (a fracture resulting from a fall from standing height or less). The decision should be made on a case-by-case basis and will depend on your individual condition.

This article will discuss medications and treatment options available to help strengthen your bones if you have osteopenia and prevent osteoporosis.

Osteopenia Medications

A number of different medications are FDA-approved for the treatment of osteoporosis. These same medications, discussed below, are also used to slow bone loss or increase bone density in select people with osteopenia.

Biphosphonates

Bisphosphonates are medications that work by slowing the rate of bone loss, thereby improving bone density. Most of these reduce the risk of spine fractures, but not all have been shown to reduce the risk of hip fractures. Some bisphosphonates are taken orally while others are given by injection.

Available biphosphonates include:

• Fosamax (alendronate): Taken orally, Fosomax appears to reduce both hip and spine fractures.
• Actonel (risedronate): Taken orally, Actonel may reduce the risk of both hip and spine fractures.
• Boniva (ibandronate): Boniva, available orally or by injection, reduces the risk of spine fractures but not hip fractures.
• Zometa or Reclast (zoledronic acid): Given by injection, Zometa reduces the risk of both hip and spine fractures.

Side effects of bisphosphonates vary based on whether they are used orally or by injection. With oral bisphosphonates, the medication should be taken with a full glass of water and you should remain upright for 30 to 60 minutes.

Possible side effects of bisphosphonates include:

• Heartburn
• Esophageal irritation
• Flu-like symptoms (injections only)
• Muscle and joint pain at the injection site

An uncommon but severe side effect is osteonecrosis (bone cell death) of the jaw. People who have gum disease or poor dental hygiene, have a dental device, or require procedures such as a tooth extraction are at greatest risk. Other uncommon side effects include atrial fibrillation and atypical femur fractures.

Selective Estrogen Recept Modulators

Selective estrogen receptor modulators (SERMS) are medications that can have both estrogen-like and anti-estrogen effects, depending on the part of the body they act on.

Evista (raloxifene) and Soltamox (tamoxifen) are hormone therapies approved for the prevention of osteoporosis in postmenopausal women. These drugs are also thought to reduce the risk of breast cancer.

Like estrogen (as in hormone replacement therapy) their action on bone increases bone mineral density and reduces the risk of vertebral (spinal) fractures. They may also reduce the risk of hip fractures, but more research is needed.

Possible side effects of SERMS include:

• Hot flashes
• Leg cramps
• Joint aches

Serious but rare side effects include deep vein thrombosis and pulmonary emboli.

Hormone Replacement Therapy

While hormone replacement therapy (HRT) was once referred to as nearly a miracle drug to prevent osteoporosis in women, it is no longer approved for this indication. In addition, studies finding an increased risk of breast cancer, heart disease, and strokes in women taking HRT have resulted in these medications being used much less frequently.

Certainly, there are still people who use HRT for menopausal symptoms, and it can work well for these symptoms. One significant cause of bone loss in menopausal women is the reduction in the amount of estrogen produced by the body. It makes sense then that hormone replacement therapy (HRT) would help reduce bone loss.

As with any medication, you must weigh the risks and benefits of any medication you use. For young women who have had surgical menopause and are suffering from life-limiting hot flashes, HRT may be a good option. Yet, even in this setting, the goal of treatment with HRT should not be a reduction in osteoporosis risk.

Denosumab

Prolia (denosumab) is a monoclonal antibody that prevents the formation of osteoclasts, cells which cause the breakdown of bone.

Denosumab can reduce the risk of osteoporosis and fractures in women who are on aromatase inhibitors (drugs for postmenopausal breast cancer), or men who are on androgen deprivation therapy for prostate cancer. Denosumab is also used for people with any type of cancer that has spread to their bones to reduce the risk of fractures.

Possible side effects of denosumab include:

• Bone, joint, or muscle pain
• Rash
• High cholesterol
• Bladder infection
• Cold-like symptoms, such as runny nose and sore throat

Serious but rare side effects include low calcium levels, osteonecrosis, and serious infections.

Calcitonin

Calcitonin is a man-made version of a hormone that regulates bone metabolism and helps change the rate at which the body reabsorbs bone. 

Calcitonin is available both as a nasal spray and by injection and can reduce the risk of spine fractures. Miacalcin nasal spray, in particular, may be an option for postmenopausal women who can't tolerate the side effects of other medications.

Possible side effects of Miacalcin nasal spray include:

• Nasal symptoms, such as runny nose, dryness, and nasal bleeding
• Back and/or joint pain
• Headache
  

Parathyroid Hormone and Derivatives

Forteo (teriparatide) is a man-made version of the body's natural parathyroid hormone administered by injection. This drug is usually used only for people with severe osteoporosis who are at a high risk of fractures.

Forteo is the only medication that can actually stimulate the body to grow new bone. Use is currently restricted to only 2 years. Tymlos (abaloparatide) is similar and is a synthetic version of a portion of parathyroid hormone.​

Possible side effects of Forteo include:

• Dizziness
• Swelling, itchiness, or redness at the injection site
• Achey joints
• Nausea

Although rare, Forteo can cause increased levels of calcium in the blood.

When Is Osteopenia Medication Prescribed?

Treatment for osteopenia can be beneficial for people with low bone density who have had a fragility fracture or who are particularly at risk for them. But, the decision to medicate is somewhat controversial for people with osteopenia who have not had a fragility fracture or do not have other risk factors.

FDA-approved medications for the prevention of osteoporosis can be prescribed to people with osteopenia. While these medications are effective, some have serious side effects. For this reason, many healthcare providers hesitate to prescribe osteoporosis medications unless they are absolutely necessary.

The decision to treat osteopenia with medications is highly individual and will depend on several factors, including:

• Age and sex: The risk of osteopenia, osteoporosis, and fragility fractures is highest in women over the age of 65, women who are post-menopausal, and men over the age of 70. Osteopenia treatment is recommended for individuals who fall within these groups.
• Overall health: People who have autoimmune conditions like rheumatoid arthritis, should be treated for osteopenia. People who have been treated for cancer should also be prescribed medication for osteopenia, since radiation and chemotherapy cause bones to weaken.
• Bone density: Bone mineral density is measured with a noninvasive test called dual-energy x-ray absorptiometry (DXA). The result comes in what's known as a T-score. Your provider may prescribe medication if your T-score is nearing -2.5, which indicates osteoporosis.
• Fracture risk: Your provider may prescribe medication if you have a history of one or more fragility fractures, an increased risk of falling due to conditions like dementia or epilepsy, poor posture, or an elevated 10-year fracture risk.

Managing Osteopenia With Lifestyle Changes

Whether or not you choose to use medications for osteopenia, there are things you can do to reduce your risk of fractures:

• De-clutter your home, keep objects off your stairs, and place slip-proof mats in your shower, bathroom, and other wet spaces to prevent falls.
• Pack your diet with nutritious foods. Get adequate calcium and vitamin D to boost bone health. Ask your healthcare provider if a supplement is right for you.
• Exercise regularly to improve strength, balance, and coordination. Make sure you do plenty of cardio, strength, and balance exercises.
• Don't smoke or use tobacco products. Nicotine in tobacco decreases the absorption of calcium in your diet and slows the production of osteoblast cells so that they make less bone.
• Limit your alcohol intake. Don't have more than two alcoholic drinks per day if you are a female, or more than three drinks per day if you are a male.
  

Summary

There are several medications which can be effective in reducing bone loss, but these all come with the risk of side effects. The decision to medicate is highly individual and depends on individual risk factors, including age, sex, T-score, and 10-year fracture risk.

If you have been diagnosed with osteopenia have a careful discussion with your healthcare provider. It's important to be your own advocate in your care, especially in a situation such as this in which treatment options must be carefully individualized.