Osteoporosis: Should I Take Bisphosphonate Medicines?

Osteoporosis: Should I Take Bisphosphonate Medicines?
Here's a record of your answers. You can use it to talk with your doctor or loved ones about your decision.

Get the facts
Compare your options
What matters most to you?
Where are you leaning now?
What else do you need to make your decision?

1. Get the facts

Your options

Take a bisphosphonate to lower the risk of bone fractures. Also use healthy habits to help protect your bones.
Don't take a bisphosphonate. Try healthy habits alone to protect your bones.

Is this information for you? This information is right for you if you are a woman who has been through menopause. You may or may not have been diagnosed with osteoporosis.

This information may not be right for you if:

You are a man.
You are a woman who has not been through menopause.
You have osteoporosis caused by another medical condition, such as cancer or a bone disease.
Your doctor told you that you have osteoporosis because of a side effect of taking medicines, such as steroids. Or you are taking steroids now or plan to start taking a long-term course of them.

If any of those describe you, or if you're not sure, talk with your doctor about this decision. Bisphosphonates may still be an option for you.

Key points to remember

The decision about whether or not to take bisphosphonates depends on what your risk of a fracture is and how you feel about the pros and cons of your options. There isn't only one right decision.
If you are at a higher risk of having a fracture, taking bisphosphonates is more likely to help you prevent a fracture. If your risk of a fracture is lower, it's less likely that these medicines will help you. Your doctor might use the FRAX tool to help predict your risk of a fracture.
Bisphosphonates can cause problems with the jaw or thigh bone. But most women do not have these side effects. They seem to be more likely if women take bisphosphonates for more than 5 years.
Whether you take medicine or not, healthy habits can help protect your bones. Get enough calcium and vitamin D. Get regular weight-bearing exercise. Avoid drinking too much alcohol. If you smoke, quit.
Bisphosphonates aren't right for everyone. Your doctor may suggest a different medicine depending on your health or if you are having a problem with side effects from bisphosphonates.

FAQs

What is osteoporosis?

Osteoporosis is a disease that affects your bones. It means you have bones that are thin and brittle, with lots of holes inside them like a sponge. This makes them easy to break. These fractures can be disabling and make it hard for you to live on your own.

What is low bone density?

Low bone density means you are at a higher risk for osteoporosis.

Low bone density is sometimes called osteopenia. It's important to know that low bone density is not a disease. It can happen normally with aging. Not everyone with low bone density gets osteoporosis or has a fracture. If you have low bone density, it is one thing that you and your doctor will talk about when you decide whether bisphosphonates are right for you.

Your doctor may suggest a test to find out your bone density, depending on your age and your health.

What healthy habits can help protect your bones?

Whether or not you take medicine, experts recommend that you:²

Get enough calcium and vitamin D.
Get regular weight-bearing exercise.
Avoid drinking too much alcohol.
Avoid smoking.

Most of these healthy habits are good for your body for other reasons, too. For example, it's good for your heart if you get regular physical activity, avoid drinking too much, and avoid smoking.

Some women decide with their doctors that they want to try healthy habits alone without taking bisphosphonates. Your doctor will probably ask you to check in over time to see how that plan is working. Having your doctor keep track of your risk of a fracture can help you know if healthy habits alone are still enough to protect your bones.

What are bisphosphonates?

Bisphosphonates are the most common medicines used to prevent bone loss in people who have osteoporosis. They slow the way bone dissolves and is absorbed by your body. They can increase bone thickness and strength.

They include:

Alendronate (Fosamax).
Ibandronate (Boniva).
Risedronate (Actonel or Atelvia).
Zoledronic acid (Reclast).

How are they taken?

Different kinds of bisphosphonates are taken in different ways. Many are taken once a week. Others are taken once a day or once a month.

Most of these medicines should be taken in the morning with a full glass of water at least 30 minutes before eating a meal, drinking a beverage, or taking any other medicine. If your doctor prescribes the form of risedronate called Atelvia, take it right after breakfast with a glass of water.

Zoledronic acid is injected into a vein in your arm. Most people who use it get just one dose each year. One form of ibandronate is also given in a vein, usually every 3 months.

What are the benefits of these medicines?

Some women may benefit more from taking bisphosphonates than other women can. It's important to find out your risk of having a fracture.

The higher your risk of a fracture, the more likely it is that bisphosphonates can help prevent a fracture.
The lower your risk of a fracture, the less likely it is that taking these medicines can help prevent a fracture.

How can you find out your risk of a fracture?

Your doctor can help you understand your risk of having a fracture. Your risk depends on several things, including:

Your age, height, and weight.
If you've had a fracture in the past.
If one of your parents ever fractured a hip.
If you smoke.
How much alcohol you drink.
The results of a bone density test, if you've had one.

Your doctor might use the FRAX tool to help predict your risk of having a fracture related to osteoporosis in the next 10 years. You can use this tool too. Go to the website at www.sheffield.ac.uk/FRAX, and click on Calculation Tool. If you have had a bone density test on your hip, you can enter your score. If you haven't had that test, you can leave the score blank.

Who is helped the most by bisphosphonates?

For women who have been through menopause:

If you have osteoporosis (your T-score is -2.5 or less) or you havehad a fracture, taking bisphosphonates lowers your risk of having a fracture. This includes lowering your risk of a hip fracture, which is a more harmful kind of fracture that can happen with osteoporosis.³
If you haven't had a fracture and you have low bone density (your T-score is between -1.0 and -2.5, sometimes called osteopenia), taking bisphosphonates might lower your risk of having a fracture. This evidence is not as strong. Experts recommend that you and your doctor think about not only your bone density but also those other things about you that affect your risk of having a fracture. That will tell you how likely it is that taking bisphosphonates might prevent a fracture.^{4, 2, 3, 1}

What are the side effects of these medicines?

Side effects can happen while taking bisphosphonate pills. For example, some women feel heartburn or irritation of the esophagus.³ These side effects can usually be avoided by following the instructions for taking your medicine.

If you start taking bisphosphonates and have problems with side effects, you can try other medicines. Talk with your doctor.

Bone side effects

Certain bone problems have been reported in women taking bisphosphonates. These side effects seem to be more likely if you take these medicines for more than 5 years.^{2, 5, 6}

Out of 1,000 people, about 1 person has a bone side effect during a year of taking bisphosphonates. That means 999 out of 1,000 people do not have a bone side effect.^{3, 5, 7}

There are two types of bone side effects:

Problems with the jaw bone. This is called osteonecrosis. Research has shown that bisphosphonates seem to increase the chance of this jaw problem. If it happens, surgery may be needed.³
A certain kind of fracture of the thigh bone. This is called an atypical fracture. More research is needed to find out if taking bisphosphonates is a cause of these fractures.^{3, 6}

How long would you need to take bisphosphonates?

Doctors don't know for sure how long people need to take bisphosphonates. That's because there hasn't been enough research to show how helpful these medicines are if you take them for more than 5 years. And the bone side effects of bisphosphonates seem to be more likely in people who take the medicines for more than 5 years.^{2, 3}

If you decide to take bisphosphonates, you and your doctor can talk over time about how long to take them, based on your fracture risk and other factors.

Are there other medicines for osteoporosis or low bone density?

Bisphosphonates aren't right for everyone. Depending on your health, your doctor may suggest other medicines to help prevent bone loss. Or your doctor may suggest these other medicines if you are having a problem with side effects from bisphosphonates.

Other medicines include:

Denosumab (Prolia).
Hormone therapy (HT) or estrogen therapy (ET).
Raloxifene (Evista).
Teriparatide (Forteo).

2. Compare your options

	Take bisphosphonates	Try using healthy habits alone
	What is usually involved? You take bisphosphonate pills on a schedule such as once a week. Or you may get a shot in a vein in your arm once a year. You and your doctor will discuss how long you'll take the medicines. You make sure you get enough calcium and vitamin D. You get regular weight-bearing exercise. And you avoid drinking too much alcohol and smoking.	What is usually involved? You make sure you get enough calcium and vitamin D. You get regular weight-bearing exercise. And you avoid drinking too much alcohol and smoking. Your doctor will probably ask you to check in over time to see if using healthy habits alone is still enough to protect your bones.
	What are the benefits? The higher your fracture risk, the more likely it is that bisphosphonates can help prevent a fracture. The lower your fracture risk, the less likely it is that these medicines can help prevent a fracture. If you have osteoporosis or you have had a fracture, taking bisphosphonates lowers your risk of a fracture. If you have low bone density (but haven't had a fracture), taking bisphosphonates might lower your risk of a fracture.	What are the benefits? You may be able to lower your risk of fractures enough without taking medicines. Or you may feel your risk of fractures is already low enough and medicines aren't worth taking. You avoid the possible side effects and cost of bisphosphonates. Most of these healthy habits are good for your body for other reasons, too.
	What are the risks and side effects? Some women feel heartburn or irritation of the esophagus. These side effects can usually be avoided by following the instructions for taking the medicine. Jaw and thigh bone problems have been reported, especially in women taking bisphosphonates for more than 5 years. Out of 1,000 people, about 1 person has a bone side effect during a year of taking bisphosphonates. That means 999 out of 1,000 people will not have a bone side effect.	What are the risks and side effects? Especially if you are at a higher risk of fractures, using healthy habits alone won't lower your risk as much as taking bisphosphonates.

Personal stories

Are you interested in what others decided to do? Many people have faced this decision. These personal stories may help you decide.

Personal stories about taking bisphosphonate medicines

These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.

"My doctor told me that I have a few risk factors for getting osteoporosis. My mother had it, and my bone density is low. Since I'm at a higher risk, I decided to take bisphosphonates and find a weight-bearing activity I can stick with. I have small bones like my mother, and she suffered terribly after she broke her hip."

— Clarissa, age 60

"I was bummed when my doctor said my bone density is a little low. But then she said, "It's not just about your bone density, Joy. We need to look at your overall risk of a fracture." When she showed me the numbers, my risk was pretty small. And my doctor said, "You're already doing all the right things to protect your bones." I like to jog and lift weights. So we decided I'll just keep doing what I'm doing, and we'll keep an eye on my risk over time."

— Joy, age 56

"I broke my hip when I fell in the bathroom. My doctor says I have osteoporosis. He told me why experts recommend medicine for people like me. I don't like pills, but I definitely don't want to break another bone. I'm going to take the medicines."

— Jaime, age 77

"My doctor used her computer to figure out my risk of breaking a bone. My risk looked pretty high. I was worried. She said bisphosphonates would lower my risk. I wasn't crazy about that. I'd read they can cause weird jaw problems. But my doctor showed me the facts, and the chances of bone side effects were a lot smaller than I thought they'd be. The meds were more likely to help me than hurt me. I decided to give them a try."

— Brenda, age 65

3. What matters most to you?

Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.

Reasons to take bisphosphonate medicines

Reasons to try healthy habits alone

I'm worried about my risk of a fracture, and I want to do everything I can to lower it.

I'm not very worried about my risk of a fracture.

More important

Equally important

More important

I don't mind taking pills or getting shots if it will reduce my risk of a fracture.

I don't like the idea of taking pills or getting shots.

More important

Equally important

More important

I'm already doing everything I can to help protect my bones through healthy habits.

I could do more to protect my bones by improving my healthy habits.

More important

Equally important

More important

I'm not worried about the side effects of these medicines.

I am worried about the side effects of these medicines.

More important

Equally important

More important

My other important reasons:

More important

Equally important

More important

4. Where are you leaning now?

Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.

Taking bisphosphonates

Trying healthy habits alone

Leaning toward

Undecided

Leaning toward

5. What else do you need to make your decision?

Check the facts

1. Should all women take bisphosphonates after menopause?

Yes
No
I'm not sure

You're right. Bisphosphonates aren't right for everyone. It depends on your risk of a fracture and your preferences.

2. Do you still need to exercise even if you take bisphosphonates?

Yes
No
I'm not sure

You're right. Whether you take medicine or not, healthy habits can also help protect your bones. Get enough calcium and vitamin D, get regular weight-bearing exercise, avoid drinking too much alcohol, and avoid smoking.

3. Do about half the women who take bisphosphonates get problems with their jaw or thigh bone?

Yes
No
I'm not sure

You're right. About 1 out of 1,000 women who take bisphosphonates for a year get jaw or thigh bone side effects. That means 999 out of 1,000 women do not get bone side effects.

Decide what's next

1. Do you understand the options available to you?

2. Are you clear about which benefits and side effects matter most to you?

3. Do you have enough support and advice from others to make a choice?

Certainty

1. How sure do you feel right now about your decision?

Not sure at all

Somewhat sure

Very sure

2. Check what you need to do before you make this decision.

I'm ready to take action.
I want to discuss the options with others.
I want to learn more about my options.

Use the following space to list questions, concerns, and next steps.

Credits and References

Credits

By	Healthwise Staff
Primary Medical Reviewer	Kathleen Romito MD - Family Medicine
Primary Medical Reviewer	Martin J. Gabica MD - Family Medicine
Primary Medical Reviewer	Elizabeth T. Russo MD - Internal Medicine
Primary Medical Reviewer	Adam Husney MD - Family Medicine
Primary Medical Reviewer	Carla J. Herman MD, MPH - Geriatric Medicine
Primary Medical Reviewer	Jeffrey N. Katz MD, MPH - Rheumatology
Primary Medical Reviewer	Caroline S. Rhoads MD - Internal Medicine

References

Citations

U.S. Preventive Services Task Force, et al. (2018). Screening for osteoporosis to prevent fractures: U.S. Preventive Services Task Force recommendation statement. JAMA, 319(24): 2521–2531. DOI: 10.1001/jama.2018.7498. Accessed October 29, 2018.
National Osteoporosis Foundation (2014). Clinician's guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation. http://nof.org/hcp/clinicians-guide. Accessed October 22, 2014.
Newberry SJ, et al. (2012). Treatment to Prevent Fractures in Men and Women With Low Bone Density or Osteoporosis: Update of a 2007 Report. Comparative Effectiveness Review No. 53 (AHRQ Publication No. 12-EHC023-EF). Rockville, MD: Agency for Healthcare Research and Quality. Available online: http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?productid=1006&pageaction=displayproduct.
Qaseem A, et al. (2017). Treatment of low bone density or osteoporosis to prevent fractures in men and women: a clinical practice guideline update from the American College of Physicians. Ann Intern Med, 166(11):818–839. DOI: 10.7326/M15-1361. Accessed October 2, 2017.
Schilcher J, et al. (2014). Risk of atypical femoral fracture during and after bisphosphonate use. New England Journal of Medicine, 371(10): 974–976. DOI: 10.1056/NEJMc1403799. Accessed January 30, 2017.
U.S. Food and Drug Administration (2010). FDA Drug Safety Communication: Safety update for osteoporosis drugs, bisphosphonates, and atypical fractures. U.S. Food and Drug Administration. http://www.fda.gov/Drugs/DrugSafety/ucm229009.htm. Accessed January 17, 2017.
Khan AA, et al. (2015). Diagnosis and management of osteonecrosis of the jaw: A systematic review and international consensus. Journal of Bone and Mineral Research, 30(1): 3–23. DOI: 10.1002/jbmr.2405. Accessed January 31, 2017.