Osteoporosis treatment options
Osteoporosis treatment improves bone strength and reduces your chances of breaking a bone. Treatment choice is based on your age, sex and medical history, as well as how severe your osteoporosis is and the likelihood of you fracturing (breaking) a bone.
Your doctor may suggest lifestyle changes to strengthen your bones, such as:
- stopping smoking;
- cutting down on alcohol;
- making sure you get enough calcium and vitamin D;
- doing exercises that have been specially designed for you; and
- taking steps to reduce your risk of having a fall.
However, if you have established osteoporosis, lifestyle measures alone will not usually be enough to strengthen bones, and you may need treatment with medicines.
Prescription medicines for osteoporosis work on your normal bone turnover process. They either increase the formation of new bone, or slow down the breakdown (resorption) of bone. Medicines used in Australia to treat osteoporosis include:
- bisphosphonates (which may be given in combination with calcium and vitamin D supplements);
- hormone replacement therapy;
- raloxifene; and
Your doctor may refer you to a specialist endocrinologist, rheumatologist or specialist bone centre for osteoporosis treatment. Your doctor may also refer you to a physiotherapist, exercise physiologist or occupational therapist to develop a specific exercise programme for osteoporosis and to help lower your risk of falls.
Calcium and vitamin D
Calcium and vitamin D are essential for bone health, and having enough calcium and vitamin D in your body is important in preventing bone loss and fractures. Calcium makes bones strong and vitamin D helps your body to absorb calcium. Vitamin D also helps keep muscles strong and improves balance. Having enough calcium and vitamin D helps many osteoporosis prescription medicines to work better.
The amount of calcium you should be getting each day from your diet depends on your age and sex - here’s a tool to calculate your daily calcium requirements.
While vitamin D is found in some foods, you would not be able to get enough vitamin D from food alone. Most Australians get the majority of their vitamin D through exposure to sunlight.
You can become low in vitamin D, especially over the winter months. People most at risk of vitamin D deficiency are:
- elderly people who stay mostly inside;
- people who are very careful about covering up and wearing a hat and sunscreen when outside; and
- people who are covered up for cultural reasons.
The SunSmart smartphone app calculates how much outdoor exposure you need to meet your vitamin D requirements, based on your location in Australia and the time of day. It also advises whether you need sun protection, based on the UV levels.
Calcium and vitamin D supplements
Calcium and vitamin D supplements benefit people at risk of deficiency. When given together, they may reduce the risk of fractures in people who have low levels of calcium and vitamin D. However, they are not routinely recommended for most people.
Calcium supplements are available as:
- calcium carbonate (e.g. Caltrate), which is best taken after food because stomach acids help the calcium absorption; and
- calcium citrate (e.g. Citracal tablets), which is better absorbed in older people.
Calcium supplements may be recommended if you take osteoporosis medicines and you get less than 1300 mg per day of calcium from your diet. If you take bisphosphonates, calcium supplements should be taken several hours apart from the bisphosphonates.
People who are low in vitamin D (your doctor can measure your vitamin D level with a simple blood test) may be advised to take vitamin D supplements. Vitamin D supplements are most commonly available as vitamin D3 (cholecalciferol).
Combination supplements containing calcium and vitamin D (e.g. Caltrate Bone Health Tablets, Citracal plus D Tablets, Ostelin Vitamin D and Calcium Tablets) are also available.
Calcium supplements may cause bloating and constipation, and can increase your risk of kidney stones, especially if taken with vitamin D supplements. There are some concerns that calcium supplements may increase the risk of heart attack, but more studies are needed to confirm this. It is generally considered safe to take supplements of calcium and vitamin D when taken as directed.
Exercises for people with osteoporosis
Your maximum bone density is largely determined early in life. However, even if you have developed osteoporosis, high-impact weight-bearing exercise and progressive resistance exercises (strength training, or weight lifting) can help maintain your existing bone density and even improve on it. They do this by building more bone and slowing the rate of overall bone loss, even after menopause.
Moderate- to high-impact weight-bearing exercises are ones that involve your feet striking the ground, such as hopping, skipping, jumping, playing tennis, jogging, basketball, netball, step aerobics, stair climbing and dancing. These may not be suitable for people with osteoporosis who have had a fracture or who are at high risk of fracture, or who have joint or balance problems. But even if these exercises are not suitable, you may still benefit from more low-impact weight-bearing exercises, such as walking.
Resistance exercises can also help with bone density. They involve lifting free weights, using weight machines or resistance bands, or doing floor exercises using your own body weight. They should be done at least 3 times per week and involve gradually adding more resistance over time. To stimulate growth of bone, it is better to do fewer repetitions with heavier weight. Experts recommend concentrating on areas around the bones most at risk of fracture - the hips, spine and wrists/forearms.
Exercise also helps reduce the risk of falls and fractures by improving muscle strength and balance. Exercises that improve balance, such as Tai Chi, can reduce the risk of you falling and having a fracture.
Pilates, when done under the supervision of an instructor, can build bone density, improve muscle strength and enhance your balance. Pilates works by strengthening the muscles of the core and back. Many standard pilates exercises are not suitable for a person with osteoporosis, but a qualified instructor will be able to design you a specific programme. Pilates mat classes are not suitable for a person with osteoporosis.
If you have osteoporosis, you should consult a healthcare professional, such as your doctor or a physiotherapist, before beginning an exercise programme. Ask about taking special precautions when exercising. A tailored exercise programme will be most effective in treating your osteoporosis. Some hospitals run special exercise classes for people with osteoporosis. If you have had a fracture, exercise can also help rehabilitate your bones faster.
Always remember to tell an instructor that you have osteoporosis before doing any exercise class, as there are many exercises that you should not do. These include exercises which put too much load on the spine, involve forward flexion (bending forwards) or involve rotating the trunk, which twists the spine. Your instructor should be able to give you a modification or alternative exercise to make it safe for you.
Bisphosphonates are a type of medicine that can slow bone loss, improve bone density and reduce the risk of fractures. Bisphosphonates are often the first type of medicine that doctors prescribe for confirmed osteoporosis in women who have been through menopause and men older than 50 years of age.
Doctors usually recommend treatment with oral bisphosphonates for at least 5 years. Extended treatment may be recommended in some cases.
- alendronate tablets (brand names Fosamax, Adronat, Alendro, Fonat), which can be taken either once per week or once daily;
- risedronate tablets (Actonel, Acris), taken either once per week, once per month or once daily; and
- zoledronic acid (e.g. Aclasta, Ostira), which is given as an infusion via a drip into a vein (intravenously) once per year.
Adequate calcium and vitamin D intake are important when taking bisphosphonates. Combination packs that include a bisphosphonate plus either calcium, vitamin D (cholecalciferol) or both calcium and vitamin D are available:
- risedronate plus calcium (brand names Actonel Combi, Acris Combi);
- alendronate plus cholecalciferol (Fosamax Plus, Dronalen Plus);
- risedronate, calcium carbonate and cholecalciferol (brand name Actonel Combi D); and
- alendronate, calcium carbonate and cholecalciferol (Fosamax Plus D-Cal, Dronalen Plus D-Cal).
Calcium supplements and bisphosphonates should be taken at least several hours apart.
Side effects of bisphosphonates
Bisphosphonates can give some people stomach upsets, causing nausea, heartburn, abdominal pain, constipation or diarrhoea. They should be taken on an empty stomach to minimise these side effects. Also, people are advised to stay upright for 30 minutes after taking risedronate and alendronate, as they can sometimes irritate the oesophagus (food pipe). Once-weekly bisphosphonate formulations help reduce the risk of these gastrointestinal side effects. Risedronate is also available as a once-a-month treatment, which may be more convenient.
Zoledronic acid, a once-a-year intravenous infusion treatment (medicine that is given via a drip into a vein), can be useful for people who have troublesome side effects with oral bisphosphonates. However, there is a risk of a flu-like reaction with this medicine.
Other side effects of bisphosphonates may include joint and muscle pain and fatigue.
A rare side effect of bisphosphonates is osteonecrosis of the jaw, which can cause severe jaw pain, swelling and infection in the jaw region, and loosening of teeth and exposed bone. This side effect is more likely if you’ve been taking bisphosphonates for an extended period of time. It is also more likely to happen if you smoke, take corticosteroid medicines, have other dental problems (such as ill-fitting dentures) or have a procedure such as tooth extraction or dental implant. Make sure you maintain good oral hygiene and tell your dentist if you are taking bisphosphonates.
Denosumab (brand name Prolia) is a monoclonal antibody medicine that slows down the amount of bone that is broken down (resorbed) in the normal bone renewal (turnover) process. This results in higher bone mineral density and reduced fractures.
Prolia is injected under the skin (subcutaneously) once every 6 months. The syringe is designed so that you can do this injection yourself, if you wish. Your doctor or pharmacist can give you a demonstration.
Denosumab can be used to treat osteoporosis in:
- postmenopausal women at increased risk of fractures; and
- as an alternative to bisphosphonates in men with osteoporosis who are at increased risk of fractures.
Your doctor may prescribe denosumab if you cannot take bisphosphonates. Initial treatment is usually recommended for 3 years. Your doctor will want to make sure you have enough calcium and vitamin D before starting treatment with denosumab. They will check your calcium and vitamin D levels with blood tests before and during treatment.
Side effects of Prolia may include joint and muscle pain, eczema and high cholesterol. Rare cases of osteonecrosis of the jaw have been reported.
Hormone replacement therapy (HRT)
Hormone replacement therapy (HRT), also known as hormone therapy or menopausal hormone therapy (MHT), can be used to treat symptoms of menopause, such as hot flushes, in some women. HRT can also help prevent bone loss, improve bone density and reduce fracture rates when given around the time of menopause or after menopause.
HRT is not routinely recommended purely for osteoporosis treatment (or prevention) because of the risks associated with its long-term use. (Long term use of HRT is associated with an increased risk of breast cancer, heart attack, stroke and blood clots.) However, HRT may be a treatment option for some younger women (before age 60) with osteoporosis who also have troublesome menopausal symptoms.
Your doctor will be able to discuss with you the risks and benefits of treatment with HRT.
Raloxifene (brand names include Evista, Evifyne) belongs to a class of drugs called selective oestrogen receptor modulators (SERMs). This medicine is used as an alternative to bisphosphonates or denosumab in women with osteoporosis who have been through menopause. Raloxifene tablets are taken once daily.
Raloxifene has been shown to reduce bone loss after menopause, and can reduce the risk of backbone (spine) fractures. There is also evidence that it can reduce the risk of breast cancer.
Raloxifene may increase your risk of having hot flushes and make them worse, and may cause leg cramps and increase the risk of blood clots and fatal stroke.
Teriparatide (brand name Forteo) is a synthetic version of human parathyroid hormone. It increases bone formation (it is the only osteoporosis medicine that does), thus increasing bone density, and reduces the risk of fractures.
Teriparatide can be used to treat severe osteoporosis in postmenopausal women or men over 50 when:
- other medicines are considered unsuitable; or
- a fracture has occurred while on other osteoporosis treatments.
It is given by injection under the skin (subcutaneously) once a day for up to 18 months. After this time, your doctor will prescribe a different osteoporosis medicine.
Teriparatide cannot be used by people who have Paget’s disease, those younger than 25 years or those who have previously had radiotherapy to bones. It can cause dizziness, nausea, headaches and leg cramps, as well as pain at the injection site.
Strontium (brand name Protos) was discontinued in Australia in 2017. If you had been taking strontium for osteoporosis, talk to your doctor about a suitable alternative medicine.
Monitoring osteoporosis treatment
Your doctor will want to see you regularly if you have osteoporosis, to check on your condition and adjust your treatments if necessary. They will perform a physical examination at your check-ups, looking for any signs of fractures due to osteoporosis.
Bone mineral density (BMD) scans can help show whether osteoporosis treatment is working. In general, if your bone mineral density has remained stable or improved, your medicine is working well. If your BMD has decreased during treatment, changes in treatment may be recommended. BMD scans may be also done if your doctor is considering changing or stopping your medicines.
Your doctor may recommend you have a bone mineral density (BMD) scan about every 2 years while being treated for osteoporosis.
Blood tests that measure so-called bone turnover markers can also be used to check that your osteoporosis treatment is working. These tests can show the amount of bone formation and loss (resorption). The tests may be done at 3 months and 12 months after the start of treatment with medicines, but are not done routinely - bone turnover markers are currently only recommended for certain people under the care of a specialist.
Support groups for osteoporosis
You may want to join an osteoporosis support group to meet and talk with other people living with osteoporosis. Support groups can provide emotional support and practical advice. Your doctor should be able to recommend a local osteoporosis support group.
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