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Injectable Medication Provides Hope for the Silent Disease

physician going over results of bone density screening

Osteoporosis Medication and How it’s Helping

By Aaron Klysen, Doctor of Pharmacy candidate 2022
5/26/2022

We’ve spoken at length here on the Network Health blog about how osteoporosis is often called the “silent disease” because it tends to fly under the radar until a fall or a fracture. Luckily, there are options for treatment. One such option with proven effectiveness is injectable medications that are working to mitigate the danger experienced with every step by those living with osteoporosis.

Why is osteoporosis so dangerous?

Osteoporosis is characterized by the weakening of bones or loss of bone structure. You will often hear the terms “bone mass” or “bone density” when medical experts are talking about osteoporosis.

Bone mass is a measure of the minerals, such as calcium and phosphorus, contained within a bone. With osteoporosis, individuals have low bone mass or fewer minerals contained within the bone, leading to loss of bone strength.

This loss of bone strength places individuals at a higher risk for experiencing a fracture. The Bone Health & Osteoporosis Foundation (BHOF) estimates that osteoporosis will lead to a bone fracture in up to one of every two women and one of every four men throughout their lifetime, many of these happening after a fall.

According to the NOF, it is thought that around 10 million Americans have osteoporosis, with 44 million more Americans experiencing loss of bone mass leading to osteoporosis. Not only is a bone fracture costly both mentally and physically, but also economically.

A 2019 report estimates the average medical cost of an osteoporotic bone fracture to be nearly $22,000 per patient. The number of U.S. adults experiencing loss of bone mass, considering the risk of bone fracture and its associated costs, highlights the importance of early detection and treatment of osteoporosis. View the Bone Health & Osteoporosis Foundation infographic on the condition by clicking here.

How do I know if I have osteoporosis?

Unlike many other conditions that have visible symptoms, most individuals do not realize they have osteoporosis until they experience a fall that results in a bone fracture. Common sites of fracture include the hip, spine and wrists.

Risk factors that increase the likelihood of experiencing osteoporosis include older age, family history, gender, low body weight, diabetes, menopause, smoking, physical inactivity and low calcium or vitamin D levels.

Some medications may also increase the risk of osteoporosis, including proton pump inhibitors like omeprazole, long-term use of steroid medications, diuretics like furosemide and other medications such as lithium or anastrozole. Because it is difficult to know if one has osteoporosis until a fracture occurs, screening is the best method for early detection and diagnosis. It is recommended that all women over the age of 65 years, and all men older than 70 years, have a bone mineral density measurement performed. Younger individuals should be screened earlier if they have several of the previously mentioned risk factors. 

How is osteoporosis diagnosed and monitored?

The current standard for diagnosis and monitoring of osteoporosis involves a dual-energy x-ray absorptiometry scan (known as a DXA scan). This scan helps determine the “bone mass” or “bone density.” DXA scans accomplish this by passing harmless beams of energy through a specific bone. Common bones tested include the hip, femur and vertebral (spine) bones.

The more of the energy beam a bone is able to block/repel, the denser that bone is. The results of a DXA scan are provided as a score called the T-score. T-score numbers indicating weak bone density show up as negative numbers. A low bone mineral density, for example, may be -2.5.

This scan is painless, takes only minutes and uses less radiation than a standard x-ray. No special precautions need to be taken other than stopping calcium supplements at least 24 hours prior to the scan. A repeat scan is usually taken one to two years after osteoporosis treatment has started.

Another tool your doctor may use in the diagnosis of osteoporosis is the Fracture Risk Assessment Tool, or FRAX. This is a survey doctors use to estimate the likelihood of experiencing a fracture in the next 10 years. The higher the score, the more likely an individual is to experience a fracture.

What medications treat and help prevent the progression of osteoporosis?

While experiencing a bone fracture or learning that you are at an increased risk of bone fracture can be concerning, there are treatments that can help slow or prevent further weakening of bones. Here are some of the most common and how they compare.

Generic Name

Brand Name

Dosage Form

How often it is dosed?

Prevention or Treatment

Price

Bisphosphonates – Work to decrease bone breakdown.

Alendronate

Fosamax

Tablet, Solution

Once daily or once weekly

Both

$

Risedronate

Actonel,                Atelvia

Tablet, Delayed release tablet

Once daily or once weekly or once monthly

Both

$$

Ibandronate

Boniva

Tablet, Intravenous injection

Oral: once monthly

IV: every 3 months

Both

$$

Zoledronic Acid

Reclast

Intravenous injection

Once every 1-2 years

Both

$$-Brand

$-Generic

Bone-Modifying Agents – Work to decrease bone breakdown.

Denosumab

Prolia

Subcutaneous injection

Once every 6 months

Treatment

$$$

Bone Metabolism Regulators – Work to promote bone formation and slow bone weakening. For use in post-menopausal women at a very high risk of fracture. Treatment limited to one year in duration.

Romosozumab-aqqg

Evenity

Subcutaneous injection

Once monthly

Treatment

$$$$

Parathyroid Hormones – Work to increase bone formation. Used for individuals at very high risk of fracture. Treatment limited to two years in duration.

Teriparatide

Forteo

Subcutaneous injection

Once daily

Treatment

$$$$

Abaloparatide

Tymlos

Subcutaneous injection

Once daily

Treatment

$$$$

Calcium – Required mineral for bone formation.

Calcium Carbonate

Os-Cal, Tums

Chewable tablet, tablet, capsule, powder, liquid suspension

1-3 times daily

Both

$

Calcium Citrate

Calcitrate

Capsule, tablet, granules

1-3 times daily

Both

$

Vitamin D – Required for calcium absorptionàCalcium is required for bone formation.

Cholecalciferol (D3)

Several

Chewable tablet, tablet, capsule, oral liquid

Once daily or once weekly

Both

$

Ergocalciferol (D2)

Several

Tablet, capsule, oral solution

Once daily or once weekly

Both

$

Pricing Legend (actual drug cost, this does not reflect member out-of-pocket price):

$=2-30 dollars per tablet/capsule/injection

$$= 60-250 dollars per tablet/capsule/injection

$$$=500-2000 dollars per tablet/capsule/injection

$$$$= greater than $2000 per month

If you’ve been on these medicines, your doctor may have recommended you have dental work done before starting. You may wonder why you must have dental work before starting a bisphosphonate (alendronate, risedronate, ibandronate, zoledronic acid).

Regular dental cleanings and good oral hygiene are always encouraged, but any major planned dental work should be completed prior to starting bisphosphonate therapy. Examples of major dental work include tooth extractions or dental implants. A doctor may decide to delay bisphosphonate therapy until after any dental work is complete. If you are already taking a bisphosphonate, a doctor may or may not have you temporarily stop taking the bisphosphonate until the dental work is complete. These precautions are taken to prevent a complication of bisphosphonate therapy known as Osteonecrosis of the Jaw (ONJ).

ONJ is a rare complication of bisphosphonate therapy, estimated to happen in fewer than 1 percent of patients. With ONJ, patients may develop a fracture of the jaw and associated pain and swelling. The risk of experiencing ONJ increases with diabetes, smoking, poorly fitted dentures, major dental work, high dose bisphosphonates, intravenous bisphosphonates, existing cancer diagnosis or treatment and steroid therapy. Nonetheless, the overall risk of developing ONJ remains extremely low. If, while taking a bisphosphonate, you notice unusual jaw pain or swelling, call your primary care provider right away.

What if my doctor recommends a drug holiday?

While bisphosphonates can help prevent worsening or even improve osteoporosis, long-term use of these drugs can increase the risk of developing a different type of fracture called an atypical fracture. This type of fracture often happens in the femur, a major bone that makes up a portion of the leg. To reduce the risk of atypical fractures, doctors will often have patients take a drug holiday.

A drug holiday involves temporarily discontinuing a medication for a defined period of time, often years. For bisphosphonates, a drug holiday is usually recommended after three to six years of intravenous zoledronic acid therapy or five to ten years of oral bisphosphonate therapy, depending on fracture risk. A drug holiday for these medications typically last up to five years.

Medication provides relief for those living with osteoporosis

Ask your personal doctor about bone health and what actions you can take to make your bones stronger. Simple adjustments, like cutting soda from your diet, adding in physical activity and increasing calcium and vitamin D intake, can make a difference in improving bone health.

For more information on how your Wisconsin health plan can help you with osteoporosis or other medical conditions, contact us today.


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