Ep 25: Preventing Fractures: Osteoporosis Medications Explained

Osteoporosis medications often get a bad rap… but the science tells a different story. Left untreated, bone loss can lead to fractures that steal independence, mobility, and quality of life. Think about the difference between confidently carrying your groceries or lifting your grandkids versus spending months recovering from a hip fracture, dealing with chronic pain, or losing the ability to live independently.

In this third and final episode of my bone health series, I'll break down the different osteoporosis treatment options, who they're best suited for, and what you need to know about side effects, safety, and timing—so you can make informed decisions about protecting your bones and your future.

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Audio Stamps

00:55 - Why osteoporosis medications prevent life-changing fractures and protect your independence.

03:20 - Who needs treatment: T-scores, FRAX risk calculations, and Rose's story of preventable hip fracture.

05:10 - Bisphosphonates as first-line therapy: proper dosing, timing, and IV alternatives for pill intolerance.

06:43 - Denosumab offers an alternative option but requires careful transition planning to avoid sudden bone loss.

07:50 - Safety concerns addressed: drug holidays, dental work timing, and separating jaw risk facts from fears.

11:58 - Anabolic therapies for high-risk patients: teriparatide and romosozumab actually rebuild bone like in Sophia's case.

15:12 - Additional options: raloxifene for breast cancer risk, hormone therapy for prevention, and calcitonin for pain.

17:44 - Lifestyle foundations, monitoring consistency, and medication sequencing to maintain independence and quality of life.

Thanks for listening. Find more info about Reset Recharge on the website or Instagram.

Transcript

Dr. Komal Patil-Sisodia 0:02

Welcome to Reset Recharge, the podcast where women's health takes center stage. I'm your host, Dr. Komal Patil-Sisodia, a triple board certified endocrinologist and women's health expert. This show is all about empowering you with the knowledge to understand your metabolic health, navigate hormonal changes, and feel confident in the conversations you're having with your healthcare provider. Whether you're managing symptoms, exploring treatment options, or just want to feel more in tune with your body, you're in the right place. As a physician, my goal is to educate on this podcast. The content shared here is for informational purposes only and should not replace personalized medical advice. If something we discuss resonates with you, please talk to your healthcare provider at your next visit. Now let's dive in and help you reset, recharge, and take control of your health. Welcome back to Reset Recharge. Today is the third and final installment in our Bone health series. I was debating how I was going to record this. Episode because osteoporosis medications are not the most interesting. And like I've said on previous podcast episodes, they've gotten a really bad rap for how they were used when they initially came out. So I know this subject isn't exactly going to win a popularity contest at a dinner party, but we're going to go through osteoporosis medications anyway because I think it is important for you to know. And while this topic may not be the most exciting thing that you have listened to all week, the impact that these treatments can have on your life is huge. We are talking about the difference between staying active and independent or being sidelined by a fracture. So give me the next however many minutes it takes me to get through this. Stick with me. I'm gonna break down the different osteoporosis medication options, who they're for and what you need to know about side effects, timing and how to make a choice for yourself. I'll try and share a few patient stories along the way as well to keep it a little interesting. But I think that you'll walk away with a good understanding of what you need to be thinking about when you're offered osteoporosis medications. So let's talk a little bit about why medications matter. When we talk about osteoporosis, what we're really talking about is the risk of fragility fractures. Those are the breaks that will happen from a fall if that occurs from standing height or even something as simple as bending over to pick up a box. I think I shared a story in one of the earlier podcasts about one of my patients who. Was refusing to get screened for osteoporosis and just went along for several years. Post menopause was doing fine until she went to move her coffee table and then she sustained a compression fracture to her spine. Her life was changed because the fracture wasn't just inconvenient. She had long-term pain, loss of mobility, and in addition to those two symptoms. Fragility fractures can decrease life expectancy, which is crazy. We want people to have a good quality of life for a long time. But here's the good news. Osteoporosis medications have actually been shown to prevent fractures, and it's not just in the spine, but in the other bones to including the hip. Now, who is going to be most likely to need these medications? Generally, women who have a bone density T score of minus 2.5 or lower. That's the official definition for osteoporosis. Those who have had a hip or spine fracture, or those who have a high risk of fracture based on something called a FRAC score. And that is, calculation that they do based on your bone density scan. And you may have readings that are in the pre-stage of osteoporosis that we call osteopenia, but this calculation looks at what your lifetime risk is for hip fractures or other major fractures. And if the risk of a hip fracture is 3% or higher. In the next 10 years, or the risk of a major osteoporotic fracture is 20% or higher in the next 10 years, then we recommend that you undergo treatment. So let me tell you about one of my patients. Let's call her Rose. Rose, thought of herself as just being a little clumsy. One icy morning she slipped and fell and broke her hip and spent months recovering. Only later did she learn that she had osteoporosis for years and that there were treatments that could have reduced her risk dramatically, and she really regretted not following up sooner. Let's talk about what you do before you hit that point. The first line therapy of osteoporosis is a class of medications called antiresorptives and these slow down the breakdown of bones. So if you think back to the first episode when I was explaining how. The bones work, there are two sets of cells. You have your osteoblasts, which are laying down brand new and your osteoclasts, which are chewing up the old bone to remodel them. So this group of medications will slow down the osteoclast, which are the ones that are in charge of breaking down the old bone that needs to be remodeled. The first line therapy are known as oral bisphosphonates, and these are things like alendronate or and oftentimes their first choice, they can cut the risk of spine fractures in half, sometimes a little bit more, and lower hip fracture risk by about 40%. Alendronate is usually taken once a week. is taken weekly or even monthly. And then there's another medication called ibandronate. It mainly helps the spine. It doesn't have as good of. Hip fracture data, but it's there as an option when you take these pills. Here's a pro tip. You take these pills first thing in the morning with water on an empty stomach, and because they're a little bit bigger, you have to stay upright for at least 30 minutes to an hour, and this will protect your esophagus and your stomach lining. If you have conditions like acid reflux or difficulty swallowing, getting down big pills, if these pills are tricky for you to take, then. There is an IV form of this called zoledronic acid that is given once a year through an iv. You're monitored for a little bit after you take it, and then you don't have to worry about taking a pill every week, every month, or anything like that. And then you just go back again for your next infusion in 12 months. So when you're taking the pills, generally we will use them for five years before we give you a break unless your bone density is getting worse. And then we'll switch to something else. And with the IV form, the zoledronic acid, we will give that for about three years before we pause and reassess and see where your bones are. Now if none of these medications work particularly well for you, there's another medication in this group of antiresorptives called denosumab. It works by a little different pathway, but it's a shot that's given every six months, and it is a great option if you cannot take bisphosphonates. Say you have the stomach issues, you can't take the oral ones, or you had a reaction to the IV infusion, but here's a warning with this one, you cannot just stop it suddenly, and doing that will cause rapid bone loss. And the potential for multiple spine fractures. So you need a plan for transitioning off of it. What I do in my practice Is when somebody completes a course of denosumab. So generally that is a shot every six months for five to up to ten years, six months after their last shot, I'll give them a dose of the IV zoledronic acid, and that is to seal in the effects of the denosumab. Most people will tolerate that pretty well. And then we watch and see how the bone density is doing before we decide whether we're gonna need to start medication again or potentially transition to another therapy. Now let's get to the important parts. A lot of people are really worried about the safety of these medications, and I have said multiple times before that these medications when they first came out were not used appropriately. By physicians and not because they were doing it on purpose, but just because we didn't know as much about the drugs then as we do know now. So my recommendations tend to be that when you start on an oral bisphosphonate, you can take it for about five years before you have to take a break. If you're doing the IV version, somewhere between three and five years because it sticks around in your system for a while. And the way that these medications work is to slow down the osteoclasts, which are chewing up the old bone that needs to be remodeled. And when you stop that process for too long, you actually can set yourself up for a higher risk of atypical fractures. And I think that's where people get scared of these medications because when they first came out, people were using them for 5, 10, 15 years without taking a break. So a lot of women suffered. Atypical fractures, but since we have learned more about these drugs, if you use them in a way where you're being monitored consistently and you know when to start and stop, it can actually create such a better outcome for women who are struggling with osteoporosis. Other side effects with these medications tend to be with the oral bisphosphonates, like the alendronate, because you have to stay upright for an hour if it's causing you any GI irritation. That tends to be the most common side effect for the IV zoledronic acid. That is generally that one's pretty well tolerated, but some people will get like a flu-like reaction to the infusion. And there are several protocols that physicians can give their patients prior to getting the infusion and after getting their infusion, that can maybe lessen the side effect of that IV infusion. Now, the biggest concern that I typically hear from my patients when they're coming in outside of the atypical fractures is the issue with jaw problems. And I really wanna talk about this because I think that this is grossly overblown. The jaw problems happen when you are giving zoledronic acid or denosumab more frequently than the regimen that you give for. Osteoporosis. For example, in people who have cancer, they're often used to stabilize bone metastases so that people don't fracture from the bone mets. In that case, people are getting zoledronic acid twice a year. They're getting denosumab maybe somewhat more frequently than every six months. And because you're getting so much drug that can impact. The ability to heal from a dental procedure. And so I will always counsel my patients that if you have upcoming invasive dental work, and when I say invasive dental work, where you need. A tooth extracted or a tooth implanted, we're actually drilling into the jaw bone. That is where you need to discuss a plan with your doctor and make sure that you have a good plan in place to heal from the procedure. If you talk to your dentist, they can give you some guidance around how long you need to be off of those medications before getting your dental work done. Usually, if I haven't even started meds, I'll have people get their dental work done and heal for a few months before we. Start therapy for them. So I hope that's helpful. But please know that if in the hands of a doctor who is experienced with these medications, the likelihood is that you'll see benefit to your bone and that you will not see these side effects. Now, I can't guarantee that for everybody because rare things happen. But again, in the hands of somebody who's trained to use these, they can be very effective tools for managing your bone health and preventing fractures. Now, let's talk about the next class of medications, and these are called anabolic or dual action therapies for very high risk patients, right? And these are people who have had vertebral fractures, multiple fractures. Hip fractures plus low bone density. Usually if a T score is less than minus 3.5, I will at least have a conversation with my patients about these medications and they are teriparatide and abaloparatide, which are basically synthetic parathyroid hormone that is given in a daily self-administered. Injection that you take daily for two years. A lot of people just balk at that and they're like, ah, I don't know that I want to give myself a shot. But these medications are actually the first to have been shown to build bone, which is phenomenal. You don't see that necessarily with the other medications, but these are reserved for patients with more serious bone disease. It's important to note that. People can only use these once during their lifetime. You do it one time for two years, and it's not really available again after that just because of the potential side effect profile of these medications. Additionally, if you have a condition called Paget's disease or you have received radiation to an area that's affecting the long bones in your body. Teriparatide and abaloparatide are not recommended because they can increase the risk of osteosarcoma in patients who fall in those two categories, not otherwise. And then we have the next drug romosozumab, which is a once monthly injection for 12 months this one in particular, works in two ways. It builds bone and it slows breakdown. All three of these medications need a dose of zoledronic acid after the therapy is completed in order to seal in the effects. So it will not take you away from zoledronic acid but zoledronic acid is used at least once afterwards. For the Romosozumab, it's important to note that there were studies showing that it may increase the risk of heart disease. So in somebody with a recent heart attack or stroke, I tend to avoid these medications. So my next patient, Sophia. Had two spine fractures within a year, and we started her on an anabolic medication. I think we decided on a vide, and within months, her bone density started to climb for the first time. Prior to that, other medications had kept it stable, but then when she fell and had the fracture. That's when we decided we needed to uplevel her therapy. It really helped with her pain due to the fractures as well as rebuilding that bone. So these tools could be fantastic for treating compression fractures. I usually like to save them for that. And now our last category of medications. These are known as the selective estrogen. Receptor modifiers. These are used in women who have breast cancer because they do reduce the risk of breast cancer. The one that has the most benefit for osteoporosis is one called raloxifene. Raloxifene will protect against vertebral fractures or spine fractures and will reduce breast cancer risks. So in women who've had breast cancer and get started on this, it's like a twofer. There's no hip benefit though. And if there is a high risk for a person to have. Blood clot, then this medication is not necessarily the best choice. The next question I get very frequently is about menopause hormone therapy. So this is where it gets interesting. Menopause hormone therapy is really only approved for osteopenia to prevent progression to osteoporosis. But there are studies that show when women who have osteoporosis and are postmenopausal are put on menopause hormone therapy. It reduces fracture risk by 20 to 40%. The problem is that if you stop the menopause hormone therapy, any benefit of that goes away. I think we need more studies because for a long time the recommendation was that women stopped menopause hormone therapy after five years, and now I think we are realizing that women can be on it for longer than was previously recommended. So I think that more studies are needed there. It is not, again, an FDA approved indication for osteoporosis, though the studies suggest. Long-term use could be beneficial. And then the last one is calcitonin, which, gosh, I don't think I've ever prescribed that for osteoporosis. It's not for long-term prevention, but if a patient has just recently had a fracture, this can actually help with pain from that fracture. You can use it for a short period of time until you get them transitioned over to another medication. And that brings me to my last patient, we'll call her Blanche. She has a strong family history of breast cancer and because of that, we opted to, and she'd had some abnormal mammos. We opted to try Roxane because she felt that it gave her peace of mind from a breast cancer risk reduction. Point of view as well as helping her bones. I did explain to her that hip fractures may not be prevented, but for now we're monitoring and we'll see how it all pans out. So things that I want to review as we wrap this episode up. Number one, the sequencing of the medications that you take, meaning the order in which you take it in, is very important. So if somebody is very high risk at their initial presentation, I will start with an anabolic medication or romosozumab before switching them to something like a bisphosphonate or a denosumab, if they're high risk. I will start bisphosphonates first and or switch to denosumab if they're not tolerating the bisphosphonates well, and you should never, ever combine osteoporosis drugs with the exception of calcium and vitamin D as supplements to help with therapy. You should not be doing, bisphosphonate plus denosumab or a Bisphosphonate plus. An anabolic or romosozumab at the same time. There's no additive benefit that way. Foundational stuff for everybody is making sure you're getting calcium a thousand to 1200 milligrams per day. Calcium citrate absorbs better than calcium carbonate. Calcium from your diet actually absorbs better than any supplemental cal. And then vitamin D three, I generally recommend at least a thousand to 2000 international units per day. Most people are vitamin D deficient, so we err on the side of 2000. The other things that you can do lifestyle wise are make sure that you're getting in resistance and balance training, cutback, smoking, limit your alcohol, and. Make sure that your environment is safe. I know I talked about that in the last episode. And then for monitoring, I will generally get a baseline bone density scan and then follow up scans every one to two years to make sure that we're seeing that effect. It's really important to know that doing a bone density scan more frequently than every year. Is not helpful. You will not see the change in your bone in six months. You need to give it that amount of time, and it's hard to wrap your brain around that because I think everybody wants to be able to see a change almost immediately. And then we need to make sure that people are being consistent with their therapy. I've had patients who started medications like. A vide or teriparatide and they, despite counseling decided to just randomly stop and then they would end up with fractures and not be able to figure out why. If you are just starting and stopping medications, that can actually be worse for your bones. So please make sure you're telling your doctors if you are planning to make a therapy change just so that they're aware and they can give you some guidance and maybe lead you down a different path. And then we need to make sure that we're planning transitions between medications, right? So if we're taking a drug holiday or a break, if we are, switching from one medication to another, that all needs to be done under the supervision of your physician who knows how to use these meds. So my final takeaway for this episode is for you all to remember that osteoporosis medications aren't just about bone density numbers. They are really about keeping you strong enough to keep living life on your own terms, whether that is hiking with your friends. Carrying your own groceries, being able to lift your grandkids, or just simply walking around confidently without a fear of a fall. So if you have questions about your bone health, talk to your healthcare provider. Feel free to send me a fan mail link if you need clarification on any part of this episode. Please include your name and email address, so we can reply to you directly Thank you all for being here today. I'll see you on the next episode. Hey there. Quick announcement before you go. I've officially opened my own practice. It's called Eastside Menopause and Metabolism based right here in Redmond, Washington. I'm so grateful to be helping women navigate perimenopause, menopause, and metabolic health. It's truly some of the most fulfilling work I've ever done. If you're interested in working with me, head over to eastside mm.com. You can book a consultation and stay tuned. I'll be launching a membership program as well as an online course for those of you outside of Washington. Lots more to come, so keep listening and thank you for being here.