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DEAR MAYO CLINIC: The bisphosphonate drugs I take for osteoporosis aren’t working in my case. My doctor has suggested a few alternatives. Any thoughts on what might be best?
ANSWER: Oral bisphosphonate drugs — including alendronate (Fosamax), risedronate (Actonel and Atelvia) and ibandronate (Boniva) — are the most commonly prescribed osteoporosis drugs. Bisphosphonates are less expensive than the alternatives, are safe in the long term, and are effective in preventing fractures. Still, some women aren’t sufficiently helped by bisphosphonates, and some can’t take them due to issues with swallowing, stomach upset, heartburn, low-functioning kidneys, or other side effects, such as bone or muscle aches.
In recent years, the drug denosumab (Prolia) has emerged as an alternative to bisphosphonates for the treatment of postmenopausal osteoporosis. Denosumab may be considered a first-line treatment for women with osteoporosis who are at high risk of fracture or in women who can’t take bisphosphonates. Since denosumab isn’t metabolized by the kidneys, it’s also a first-line option for women with more advanced chronic kidney disease.
When it comes to improving bone density and reducing fracture risk, denosumab may provide better results than do bisphosphonates. As with bisphosphonates, it has a small risk of serious side effects, such as skin infections, headache and fatigue. For people with osteoporosis, the risk of a condition in which the jawbone doesn’t heal following an injury, such as having a tooth pulled (osteonecrosis of the jaw), appears to be lower with denosumab than it is with bisphosphonates. Long-term use of denosumab over eight years has been shown to be both safe and effective. Still, denosumab may not be covered by insurance, unless a trial of bisphosphonate drugs has been attempted.
Denosumab is given by an injection just under the skin (subcutaneously) every six months, meaning you don’t need to remember to take your osteoporosis pills, and it won’t bother your digestive system. The bisphosphonate drug zoledronic acid (Reclast), another option, can be given once a year by intravenous infusion.
Other drugs occasionally used to treat osteoporosis include teriparatide (Forteo), a drug often reserved for the treatment of severe osteoporosis. It requires daily subcutaneous injections. Oral raloxifene (Evista) isn’t as effective in preventing fractures as either bisphosphonates or denosumab, but there are very select situations when these drugs may be considered. (adapted from Mayo Clinic Health Letter) — Dr. Kurt Kennel, Endocrinology, Mayo Clinic, Rochester, Minnesota