Starting an osteoporosis drug? Here’s what you need to know

Maneet Kaur, MD


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Human life expectancy has doubled since 1800. It is a tremendous success story for humankind — but each success brings more challenges to overcome. Because many people are living longer these days, one of the biggest responsibilities of modern medicine is to provide care and treatment for those diseases that become more common with increasing age. One of those diseases is osteoporosis, a thinning and weakening of the bones, which means they break more easily. They can break easily. Osteoporosis can compromise quality of life if it leads to a fracture, and complications of fracture can even lead to death.

Osteoporosis: The “silent enemy”

Osteoporosis is most common in older people, especially (but not only) in women. In many cases, it is first revealed by a sudden fracture — and by the time that happens, it is too late to go back and prevent this dreadful event, which can lead to many complications. According to an article published in the Journal of the American Medical Association, each year Americans suffer from 1.5 million osteoporotic fractures, resulting in more than 432,000 hospital admissions, almost 2.5 million medical office visits, and about 180,000 nursing home admissions. Medicare currently pays for approximately 80% of these fractures, with hip fractures accounting for 72% of the total cost. And because people are living longer (and are therefore more likely to get osteoporosis), the cost of osteoporosis care is expected to rise to $25.3 billion by 2025.

Why not more treatment for osteoporosis?

Despite the availability of cost-effective and well-tolerated treatments that can reduce fracture risk, only 23% of women ages 67 or older who have an osteoporosis-related fracture receive either a bone mineral density test or a prescription for an osteoporosis drug in the six months after the fracture. There are also many available options for preventing and treating osteoporosis before a woman ever experiences a fracture.

Why are so many people, especially women, not receiving osteoporosis treatment? In part because these treatments have faced multiple controversies. Many women have questions when they’re offered preventive treatment, such as: Can calcium supplements increase the risk of heart disease? What will happen to my jawbone if I take this medication? Will this pill give me esophageal cancer? And if I’m not hurting, why do I need treatment at all?

Fortunately, we have some good data to help answer these questions.

What you need to know about osteoporosis prevention and treatment

First, a few points about clinical studies in general. Every study has limitations, and we should keep them in mind while interpreting the results. For example, the population that was studied might be different from the one you belong to, so the results might not be applicable to you. Also, the number of subjects enrolled in the study and any confounding factors — other things that could influence the study results, such as lifestyle factors — should be taken into account when drawing conclusions. Despite these limitations, we have learned quite a lot about the benefits and harms of osteoporosis treatments.

  • To date, the consensus is that there has been no proven risk of increased cardiovascular risk with intake of calcium supplements.
  • Other studies have examined the risk of damage to jaw tissue with the use of bisphosphonates, one type of medication commonly used to treat osteoporosis. The risk is real, but rare. Most often, it is associated with bisphosphonates given intravenously, not taken by mouth (as most bisphosphonates are). Certain population groups are also at higher risk for necrosis than others. Talk to your doctor about your personal risk for serious bisphosphonate side effects.
  • Another common question is whether osteoporosis medications are harmful to your esophagus and the rest of your digestive tract. There is a risk of inflammation of the gut lining, but if you follow the directions carefully while taking the medication and follow up with your physician as directed, the risk is very small.
  • Because osteoporosis is a silent disease until a fracture occurs, women often question the need for treatment at all. There are guidelines and tools designed to help you and your doctor decide whether to start treatment, and as a patient, you have the right to know every detail of the treatment options being offered. One of the many available resources to get more information about this disease can be found here.

Your doctor should be able to help you decide by providing all the relevant information and explaining the major side effects of any treatment he or she recommends. From there, you should be an active participant in your own care. Weigh the risks and benefits in your own mind — and with your doctor — before you decide about treatment for osteoporosis.


  1. Pam

    The article seems very light, and does not get into spontaneous femur fractures and the question of whether drugs that slow bone remodeling like Bisphosphonates and Prolia produce a denser but unnatural bone matrix that is actually more brittle. I was diagnosed at age 40 with OP and over the course of years have taken Forteo, and Actonel off and on. Nothing increased my bone density, but I still have never had a fracture in over 15 years.

    I am left wondering that if some people merely have a lower bone density than what science considers the norm, but still have a perfectly healthy bone matrix and flexible bones that don’t need medication. Is it overkill to begin giving OP drugs to women who are only in their 40’s? Does science really know what the effect of such drugs are on a woman over 40 years? Probably not, because any deterioration while on the drugs…..would be swept under the rug saying that if it weren’t for the OP drugs it would have been worse. They really don’t know, and I suspect the scientists also don’t care since they aren’t the ones risking their own bodies with these drugs.

  2. مد لباس

    hi, great post. thank you very much for best post.

  3. Elba

    Any information on intravenous pamidronate. I had one a year ago and I am about to have a second one soon.


    I have taken tetracycline for 20 years to prevent bone deteration. W;hy is this not discussed more?


    I am one of these women who refuse to take it…..this stuff the Big Pharma is coming up with is NOT treatment….it is TORTURE. I WANT to live whatever life I have free of Pain….not added to it by drugs.

    I walk faithfully, do balance exercises, and eat healthy….that is good enough for me….AND I FEEL GREAT1

  6. Lallie Wetzig

    I used Forteo for 2 years and afterwards was told to use the very safe new drug Prolia. I had 2 injections (Dec. 2010 and June 2011). No problems until in Nov. 2011 I had difficulty walking. Doctor thought I needed hip replacement and gave me a 3rd injection in Dec. Surgeon ordered an MRI and I was found to have stress fractures of the right hip. Later a pelvis fracture and other problems. The National Osteoporosis Foundation has a website Inspire which has other stories-some good, some bad.

  7. KayJo O.

    All of this info. Makes me very uneasy. My MD advised taking Acttonel, then Fosamax, followed by Evista & Reclast (at least last 5-8 yrs.). Now 70, my back is bent over, spine is an S shape & no longer supports me. I use a cane or Walker. Severe back pain 11 yrs. Ago required an opioid & spinal stimulator plus Nucynta at bedtime for pain management. This is only 1 area that’s an issue. Add RA, glaucoma, emergency corneal transplant, worn, can’t be replaced due to poor eye tissue, IBS, hypothyroid, carpel tunnel returned after successful surgery, cubital tunnel surgery, residual effects of severe, bilateral, congenital clubfeet. Feel better? Perhaps you have only one issue!

    • Allison

      KayJoO, in other words the series of osteo drugs was responsible for the spinal deformation and other ill effects as far as you can tell? If so, this is a very telling testament to the failure of these drugs to live up to their billing.

    • William

      I am a gentleman who has been on Fosamax for about 3 years. My bone thickness has gone from the lowest 5% to the 40% level as of November 2015. The only problem I’ve had is it bubbles in my stomach and for about five minutes, I feel like throwing up. I take it with a full glass of water. The only other thing that might be associated with it is my finger nails have become more brittle, but I just keep them shorter. All in all, it is inexpensive, easy to take, and seems to be having the needed results. It’s gotta’ be better than breaking a hip or leg!

    • SylviaG

      Have you been tested for hyperparathyroidism? If your glands are not working properly (calcium levels in the 9’s or 10’s and normal high PTH), the calcium in your blood is coming from your bones. It does not matter how much medicine you take, the medicine carries calcium to the bone and the PTH takes the calcium back from the bone to the blood. Hyperparathyroidism is diagnosed more often at age 66. My doctor failed me. I found information in the internet, found a specialist and had surgery: 2 bad glands, with adenomas. Surgery length: 20 minutes, next day back to work.

  8. Eva

    After having three fractures, one serious because I ended with permanent plate and 9 screws in my ankle I decided for more calcium. Such a mess. It accumulated in my left lobe, creating tumour, which was removed a few years ago.
    5 years ago I stopped calcium supplements and I am getting my calcium from food only. Almond milk, cheese… Started to use K2,magnesium byglicinate bio identical Estriol and Progesterone topical. My bone density at age 64 went up 14% after 10 months. My hormones were balanced, without raising systemic level of estrogen. Feel like 35!!

    • Helen Lundgren

      I am so happy for you! I feel very encouraged by this also.

    • Rose

      Hello Eva
      I am so happy that your hormones balanced out with the bio identical hormones. First question to you. Did your PC prescribe the hormones for you and secondly, why did you get off your calcium meds? Thanks.

  9. Vinoo Bhagat

    Why is there no reference to vitamin K-2 or magnesium in the discussion? Lack of both (or either) is said to be a cause for osteoporosis.

    • Eva

      Excactly.These 2 are the magic bullets delivering the calcium to bones and teeth.
      They are supplement there is no money for Big pharma, so they will not talk about it.
      Billions of dollars are only in patented pharmaceutical drugs.

  10. Penny

    I’ve been researching, since I don’t want to use biophosphonates. Read about a study that just came out in Integrative Medicine journal on Ostinol – a bio protein that builds bone. The results showed an average bone density growth of 10% in 8 months and 51% in 34 months. Not a drug. neutraceutical or bioceutical. I think Life Extension has a version too. Can get at various online companies and Amazon. I’m taking the highest dose they make. Also starting low dose hormone replacement therapy. I have a friend who takes bio-identical hormones and just had a great dexa scan. So I’m adding the hormones too. I will check back in with results as I go along.

  11. Richard Hauley DMD

    Dr. Kaur has NOT done her homework. The mechanism by which bisphosphonates work has been in the literature for at least 10 years. And the problems with Bisphosphonates are NOT rare. Bisphosphonates kill osteoclasts DEAD. Since the osteoclasts are dead, the osteoblasts just keep laying down bone. Bisphosphonates increases the bone density to a point where capillaries get smaller and smaller, eventually closing them off and then blood can’t get to the periosteum and whatever class of tissue is on top of the periosteum. Since the gingiva in the mouth is very sensitive to the loss of capillary blood the gingiva dies and open, frank holes straight to the bone is observed. This is a big problem in dentistry. Patients that have been on ANY class of bisphosphonate therapy for six months or longer are in GREAT danger when doing root canal treatment or periodontal surgery or extractions, not because of the treatment, but because the wound or abcess DOES NOT HEAL because of the limited blood supply. Long bones have the same problem but it just takes longer. I take my patients OFF of those damned bisphosphonates, put them on 2000 iu’s of Vitamin D each day, have them take their calcium in soft gel tablets and have them start a weight-bearing exercise program. Anybody taking hard rock calcium such as calcium citrate or calcium carbonate can watch those damned rocks go through the gut on abdominal x-rays, never absorbed and finally exiting into the toilet. They are a total waste of money. Beware of the bisphosphonate drug salesman, he does NOT have your patient’s health in mind. Lawyers are advertising for patients with ONJ. If you are prescribing bisphosphonates indiscriminately, you and your legal team may have to defend yourself in court over this matter.

    • Helen Lundgren

      Thank you, thank you, THANK YOU, for this information! God bless you!

    • jean watson

      I am 77 and have been taking calcium for years and found out thru this that the calcium has carbonate in it am so glad to find out that I have been putting it in and then out, will have to find a calcium without this in it, thank you

    • Bexy Moya

      Thanks for this information. Many of the doctors prescribing these medications ignore the patient’s complains about the terrible side effects of these medications.

  12. Shirley Buchberger

    Does anyone have experience on Reclast and jaw necrosis? I’ve had at least five Reclast treatments and due for a root extraction in my upper left gum next week.

    • Richard Hauley DMD

      Shirley, Reclast is one of the worst bisphosphonates that you can take. You are at a high risk of the extraction NOT healing, leaving you with an open hole in your jaw bone that never heals. Every Oral Surgeon I know does not want to see any patient on Reclast or Zometa. The half life of Reclast and Zometa is 10 years. Get competent information from your Oral Surgeon.

      • Andrea

        An endocrinologist just prescribed Reclast to me. When I brought up my concerns about the effects on the jaw and my own situation in particular, she replied that she had only had one patient get ONJ and that ‘it wasn’t that bad.’ I didn’t accept the prescription after that.

  13. Eleanor Magpale Gonzalez

    I have osteoarthiritis on my knees. I took AgeLOC Youth Span in
    September 2015 and the pain has not recurred since.It is herbal in that it uses only organic materials and goes through a six- process screening! Look it up at you tube if interested.

  14. judy Woolston

    I received my 3rd IV infusion of Reclast last October. I developed my 1st tooth ache in 35 years & saw my dentist , who referred me to an oral surgeon. When he read my medication history he said ” did they tell you that no oral surgeon would ever pull a tooth after you have had Reclast due to the chance of necrosis of the jaw bone” . Needless to say I was shocked . To solve my problem, it was necessary to coordinate an appointment with a root canal specialist & the oral surgeon @ the same time & I was given a conscious anesthesia , due to my allergic reaction to local anesthetics . The tooth was cut off below the gum line& treated to stop the tooth ache, & took several months for the wound to heal. I agreed to the Reclast, because I have GI problems & couldn’t take the oral meds. They said my risk was 30-35 % chance for a spontaneous fracture. Word of advice, have a very frank talk with your specialist before you agree to this treatment. I dread having another tooth ache, & it cost over $3000 out of pocket too!!!

  15. SC

    Using low dose HRT- hormone replacement (estrogen/progestin) is still a good option for prevention of osteoporosis.

    • Sylvia Pemberton

      Depends if you want to trade the possibility of getting cancer from hormone replacement therapy and this is a very real risk!

      • M Pietersen

        The risk of cancer from HRT is still debated. I had HRT for 23 years, now off since 8 years. So far I’m OK, and I’m not really worried, although I do go for regular check-ups. I have GI problems, not serious, but get that checked too. I did have one year on oral Fosamax. When I got bone density checked after 1 yr, it turned out I didn’t have osteoporosis at all. the first scan that said I did was not properly done. Fortunately I live in Australia and get subsidised scripts. But it is a waste of resources.

      • Eva

        I am on low bio identical Estriol and Progesterone for 5 years. Every year tested my hormones.Bio identicals are used in Europe over 35 years. No concerns of cancers, like Estrogen /Progestin pharmaceutical.

  16. Greg Reilly

    I get tired of so many articles that downplay or ignore osteoporosis in men. This one makes it sound very rare in men. Most websites say it’s half as common in men, and that represents a very large number of people. But my rheumatologist says that if you define it by vertebral fractures rather than test results, it’s equal in men and women.

    I bet the number of men getting tested is far fewer than 23%! Almost all men and women that I talk to think men can’t get it at all. And I bet the number of men suffering from lack of awareness is a lot higher than the number of women. Doctors should be raising awareness for all people but perhaps for men even more than for women!

    • William

      Hey Greg, you are one hundred percent correct! I’m a guy and the only reason I was ever tested was because I started with a new Endocrinologist. The new doc was taught at George Washington University in DC by my first Endo and is very sharp! I also take Synthroid and for that reason, the new Endo caught the bone problem. She also caught the Vitamin D3 problem and has that corrected as well. I consider myself a very lucky guy!

  17. Nancy Janitz

    I had Spontaneous Hemmoraging In 1996, after taking only “1 Prescription Nsaid Tab For a period of *3 Months! I had No Signs or Pain; By the Time I daw Blood in The *Toilet and went to “ER- I was almost Ready to Die!! So, No Meds except **Tylenol! (Hat is Why when the “Sciatica Pain Started, My Only Option for *Pain Relief and Mobiility was and Still is an “Epidural in Lumbar Area of **Corticortisteroids!!” Which, also prevents me from Taking any Meds or Herbal Supplements that **Thin Blood!” So, I Am “Stuck and Don’t have Many Options”?!

    • Kiran

      Family members had low back pain, above the buttocks and bilateral low back. Doctor recommended physical therapy after, MRI and x-rays, showed no herniation or abnormality. PT followed by regular work out at the gym to strengthen abdomen muscles and stretch out ham string muscles has helped relieve some of the pain. Surprised to read of the extreme measure of steroid injections and epidurals for your back pain. Repeated use of steroids for relief of pain bring with them long term problems. Steroids have a long list of side effects, osteoporosis, GI bleeding, weight gain, mood changes, effect on immunity, fluid retention and elevation in blood pressure. In your case the doctor must have eliminated all conservative measures as being not effective. I would seek another medical opinion. Alternative therapies such as massage and acupuncture for pain relief, physical therapy and yoga to stretch out and strengthen muscles should be tried.

  18. Barabara Woodfield

    Very disappointed in this article. More like an advert. than medical advice. MMmm. Food for thought.

  19. Rita Wells Clarke

    My friend had a spontaneous femur fracture from taking Fosamax. So my osteo-specialist offers me a pharma and says, “Note it has a Black Box warning.” He would not say that he recommended it so I don’t take it. Yes, we can take daily Calcium – which one? Each “nutritionist” has a different scary story about Calcium supplements. I’ve never been able to sell myself on the drugs, mainly because not ONE doctor agreed which one. So, last Sept. I fell and fractured my hip; had surgery. Not a single doctor involved in my treatment – NOT ONE – recommended I take drugs to build bone. And you think that we can figure any of this out when the medical profession is stumbling along in the dark? Oh, please.

  20. Bonnie

    I had read that the drugs stop bone loss, but neither build new bone nor allow new bone to build. I used to drink a lot of soda, but no longer do and I hope it has slowed my bone loss down. I take a skeletal supplement, exercise, and eat right now and hope that’s enough, because I don’t trust the drugs.

  21. Carolyn Henry

    A friend aged 84 took one Prolia injection and within days her jaw came “unhinged”. This happened again about a week later. She was told it would take 6 months to overcome this side effect. In the meantime she is existing on only soft foods and liquids.

  22. Franci

    Also, we should be reminded to be careful while walking, be careful on stairs, curbs, etc. Use a walker if and when we need to. Avoid slippery rugs, and unstable, slippery shoes. So many precautions that many of us don’t think about. Slow down, don’t rush. Yes, I recall the HRT that many were prescribed to harden bones, etc. Excellent comments, so far. Good luck to all, and be careful, don’t rush around. No running to the phone; thinking of all of the telemarketer phone calls right now…..

  23. Maizie Bireley

    If bisphosphonates can cause necrosis of the jaw then what’s happening to the rest of a person’s bones? Certainly, a bisphosphonate is not a “smart” drug targeting and causing problems with just the jaw bone. If bisphosphonates can cause “mushy” jaw bones wouldn’t it be the same for the other bones in the body? And, why does this problem occur for some and not for others? Might it be that it always occurs but to certain degrees?

    Experts: enlighten me please!

    • Nancy Nussbaum

      I have this exact same question. What is the mechanism that causes this side effect? And what are the possible subclinical side-effects?

    • T.A. Smith

      According to my dentist who recognized *loss* of my lower jaw bone – not the bone being “mushy”- that the loss was due to the extended use of Fosamax. Literature I’ve read about jaw bone loss and Fosamax, altho not absolutely conclusive, appears to raise enough concern that if I knew ‘back then’ when the arthritis doc told me to take it, I would have refused.

    • Barb

      that’s it. I don’t believe there are any experts in this area. Try this on for size. I was diagnosed with osteoporosis when I was 54, that was 6 years ago. I don’t know what to do. My blood calcium level is high so I can’t take calcium anymore. I was taking 1000IU of D3 but I read somewhere that it’s useless without calcium. My insurance approved Prolia but I’m too afraid to take it. I’ve been to 3 different endos and not one has told me whether I have hyperparathyroidism or not. I do have thyroid disease and take synthroid for over 30 years. I need a knowledgeable professional hero to change the condition of my health.

  24. Jerry Amos

    Here’s what Harvard should be pushing, prevention first:
    Journal of Gerontology 55 (2000) M585-M592 Frasetto et. al. “A high ratio of vegetable to animal protein consumption was found to be impressively associated with a virtual disappearance of bone fractures (in elderly women)”. A more convenient summary and chart is on pages 206-208 of “The China Study” (2006) by Cornell nutritional biochemist prof. T. Colin Campbell. This is a very effective way to really reduce osteoporosis risk. I’m 81, we ski, I fall hard, no breaks. My wife’s recent lower spine, pelvis and lateral hip Xrays show satisfactory bony mineralization. Plant foods instead of drugs.

  25. T.A.Smith

    My arthritis doctor prescribed Fosamax and Plaquenil – neglecting to tell me that Fosamax could cause necrosis of the jaw, and because Plaquenil could affect the colour receptors in the eyes, it was important to have eyes checked every 6 months.
    When my dentist observed an extreme loss of my lower jaw bone and found out I had been taking Fosamax for several years, he advised me to discontinue that drug (too late to help, unfortunately).
    During a yearly eye exam for possible cataract surgery, I mentioned taking Plaquenil and the opthalmologist said that because that drug can affect/even destroy the eye’s colour receptors, that my eyes should be checked every 6 months.
    Fortunately I found that out before damage was done, unlike the Fosamax disaster.

  26. Grant Roberts

    Instead of pushing drugs and listing the contraindications … why not promote weight bearing exercise and optimum nutrition – side effects include stronger bones, increased lean muscle, enhanced mobility, independence and ultimately a longer happier life.

  27. Lynell Ross

    As a Certified Health & Wellness Coach, and a Certified Personal Trainer, I learned that exercise– weight bearing–exercise helps prevent osteoporosis and strengthens bones. Exercise and eating nutritious foods should not be overlooked as prevention. In addition, we get all the benefits of keeping us healthy overall from eating well and exercising at every age.

  28. Laura Long

    The side effects of the available drugs to treat osteoporosis should not be minimized. Fosamax cannot be taken for more than 5 years. Beyond that, I took Prolia and suffered an extreme reaction after 3 doses: very severe bone pain and a nasty rash. An alternative drug had a list of side effects and warnings as long as my arm! One of them was blood clots. I declined the drug. I think the medical profession should do more research on the benefits of weight-bearing exercise and physical therapies to ward against bone fractures. And the effect of diet also should be emphasized.

  29. Maizie Bireley

    Isn’t it true that bisphosphonates prevent the turnover of dead bone cells, thereby, giving the appearance of higher bone density on bone scans, but not necessarily healthy or stronger bones? Additionally, aren’t there issues with atypical fractures when taking bisphosphonates? Botttom-line: Do bisphosphonates make bones stronger and, if so, how much stronger – factually. Or, do bones just look stronger on scans due to the retention of dead bone cells?

    For years, it was standard medical practice to put menopausal women on hormone replacement therapy until it was determined that it is not healthy to do so as a standard practice. Are we going to come to the same conclusion with bisphosphonates?

  30. Ruth S.

    Dr. Maneet Kaur, MD,
    You fail to mention in your article the risks for atypical fractures of the femur associated with many osteoporosis medications.
    see articles: perhaps the information in these articles may be repetitive, the information is still extremely relevant and must be weighed against the other options. I choose to increase calcium, and begin weight-bearing exercises. and get tested again in 18 months.

  31. Gwenn Marie

    Dr. Loren Fishman and colleagues at NYU have done a years-long study about the benefits of certain yoga poses that benefit the skeleton. His findings suggest that yoga is as effective or more so than questionable pharmaceuticals. Featured in the New York Times December 2015:

  32. Diane Black,MS,RD,CDE (ABD)

    World reknowned specialist, Dr Susan Ott at the U of WA….does research most days seeing patients only one day a week.
    Good Luck with treatment!

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