Bisphosphonates, Prolia & Forteo in Osteoporosis Treatment

When I started practicing clinical medicine in South Florida there were few if any treatments for osteoporosis. We saw the devastating effects of this condition in lean post-menopausal women in their seventies and eighties – especially those who had multiple pregnancies and smoked. In men we were more likely to see it in male smokers taking corticosteroids for an inflammatory disease.

Spontaneous collapse of their vertebrae leading to nerve compressions, brutal unrelenting pain and at times neuromuscular injuries preventing walking were common. If we measured height, we saw a decrease in height over time before these catastrophic spinal injuries occurred. We also saw a plethora of spontaneous hip fractures which occurred causing a fall with trauma. In most cases, both presentations resulted in major and extensive surgery and rehabilitation before a patient resumed their life. The only medications we had at the time for women were estrogen and progesterone which carried their own list of potential adverse effects.

The introduction of oral bisphosphonates changed that. Medications like Fosamax, Actonel, Boniva slowed down the process and, with weight bearing exercise, smoking cessation, appropriate nutrition, and luck, reversed it. These medications in pill form were tough to take and still are. They are large, poorly absorbable and require you to take them on an empty stomach while upright. Most instructions call for drinking eight ounces of water with the pill followed by another eight ounces of water after the pill then staying upright for 30-60 minutes. These pills are extremely corrosive if they get caught in your esophagus because you didn’t swallow them with water. They can upset the gastric lining of your stomach as well.

Bone Densitometry tests allowed physicians to detect and then follow serially over years the thickness of your bones. I believe due to the size of the pills and the gastrointestinal problems they can cause convincing patients to try these medications has always been a difficult prospect. Fortunately, much of the responsibility falls on the gynecologists who look for osteoporosis and osteopenia as part of their evaluation of perimenopausal women routinely.

For those individuals unable to tolerate these oral medications, or unwilling to try, rheumatologists have injectables to help the bones. Prolia (denosumab) an injectable given every six months, and Forteo, (teriparatide) a daily injectable, were developed. They too can produce side effects including back and bone pain and a host of others. The good news is they work.

In a recent study of 50,862 women published in the journal Therapeutic Advances in Musculoskeletal Diseases researchers from the University of Verona, Italy led by Giovanni Adami, found that the oral medications can reduce the risk of fracture by 30% while monthly Prolia did so by 60% and daily Forteo by 90%. The significant difference was the fact that the oral agents required one year of use before the risk of a spontaneous fracture occurred while the injectables achieved success much sooner. While rheumatologists and gynecologists surmised this was occurring, this study provides solid evidence to back up their hunches.

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