Postmenopausal osteoporosis treatment by type — a brief overview of treatments

There are many medications available for the treatment of osteoporosis. The main purpose of treatment is to increase bone mass to help reduce the risk of fractures and to avoid additional decrease in bone density. Talk to your doctor to determine whether medication for osteoporosis is right for you, and if so, which medication is most appropriate. Your doctor will also help you decide how much calcium and vitamin D you need to take, in addition to your osteoporosis medication.
Adapted from Osteoporosis Canada

RANK Ligand inhibitors

RANK ligand is a protein which is responsible for activating the cells that break down bone (osteoclasts).
Blocking RANK ligand inhibits the development and activation of the cells that break down bone (osteoclasts). This action strengthens bones by increasing bone mass, and reduces the risk of breaking bones (fracture) at the hip, spine and other non-spine sites
Taken as an injection under the skin every six months

Bisphosphonates

Bisphosphonates incorporate into the bone and slow down the action of cells responsible for breaking down bone (called osteoclasts). By slowing down osteoclasts, bone-building cells (osteoblasts) can do their work to increase bone mass
Typically taken by mouth (tablet) daily, weekly or monthly, or by yearly infusion

Hormone replacement therapy (HRT)

A woman experiencing menopause will have decreased levels of estrogen, an important hormone that plays a role in maintaining bone mass. In postmenopausal women already diagnosed with osteoporosis and vertebral fractures, estrogen may help retard further bone loss
Taken as a patch applied once or twice weekly

Selective estrogen receptor modulators (SERMs)

A decline in estrogen following menopause causes a loss in bone density – sometimes this loss is so severe that it can lead to osteoporosis
SERMS are non-hormonal drugs that act like the hormone estrogen in certain parts of the body. In the bones SERMs promote the building of new bone
Taken as a tablet once a day

Parathyroid hormone (PTH)

PTH is a hormone found in the body that regulates calcium and phosphate metabolism in bone and kidney
PTH works by stimulating osteoblasts to generate new bone faster than osteoclasts (cells that break down bone), thereby increasing bone density
Taken as an injection under the skin everyday

Calcitonin

Another type of hormone found in the body, calcitonin is made by the thyroid gland, which helps control the activity of osteoclasts (cells that “eat” away at bones)
Calcitonin slows down osteoclast activity. As the rate of osteoclast activity is reduced, this allows osteoblasts (bone building cells) to work at adding more mass to bones, thereby increasing bone density
Taken as a nasal spray once daily

Specific treatments for postmenopausal osteoporosis in Canada — at a glance:

RANK Ligand inhibitor	How it works	Indication	How is it taken?
Prolia* (denosumab)	Inhibits RANK Ligand, a protein which activates the cells that break down bone (osteoclasts). This action strengthens bones by increasing bone mass and lowers the chance of breaking bones of the hip, spine, and nonspinal sites.	Indicated for the treatment of osteoporosis in postmenopausal women who have an increased risk for fractures or cannot tolerate other osteoporosis medicines, or have failed on previous treatment	Subcutaneous injection every six months
Bisphosphonates	How it works	Indication	How is it taken?
Aclasta* (zoledronic acid)	Slows down bone resorption (caused by osteoclasts), which allows the bone forming cells (osteoblasts) time to rebuild normal bone	Treatment of osteoporosis in postmenopausal women to reduce the incidence of hip, vertebral and nonvertebral fracture	An infusion (IV) that is administered once a year
Actonel* (risedronate)	Helps to increase bone density. Rebuilds some bone that has been lost and thus helps reduce the risk of spine and non-spine fractures	Treatment of osteoporosis in postmenopausal women, men and in patients receiving corticosteroids that have glucocorticoid-induced osteoporosis	An oral tablet that is taken either: once daily once a week once a month (two consecutive days)
Actonel* plus calcium (risedronate plus calcium carbonate)	Helps to increase bone density. Rebuilds bone that has been lost and thus helps reduce the risk of spine and non-spine fractures. Calcium carbonate helps to provide the calcium that your body may need to harden new bone	Treatment of osteoporosis in postmenopausal women	An oral tablet that is taken once a week, plus 1 calcium tablet daily on the other 6 days of the week
Didrocal* (etidronate plus calcium carbonate)	Increases bone mass in the spine	Treatment of osteoporosis in postmenopausal women	Oral tablets taken once daily for 14 days, followed by once calcium tablet daily for 76 days
Fosamax* (alendronate)	Increases bone mass and prevents fractures, including those of the hip and spine	Treatment of osteoporosis in postmenopausal women, men and in patients that have glucocorticoid-induced osteoporosis	Oral tablet taken either: once daily once a week Oral solution taken once weekly
Fosavance* (alendronate + cholecalciferol)	Alendronate increases bone mass and can prevent fractures, including those of the hip and spine. Cholecalciferol (vitamin D₃) plays a role in absorption and regulation of calcium	Treatment of osteoporosis in postmenopausal women and men	An oral tablet taken once weekly
Hormone replacement therapy	How it works	Indication	How is it taken?
Climara* (estradiol hemihydrate)	Treatment may retard further bone loss	Treatment of osteoporosis in postmenopausal women already diagnosed as having osteoporosis and vertebral fractures	Transdermal patch changed every seven days
Estradot* (estradiol-17β)	tTreatment may retard further bone loss.	Treatment of osteoporosis in postmenopausal women already diagnosed as having osteoporosis and vertebral fractures	Transdermal patch applied twice weekly, worn continuously for 3-4 days
SERMs	How it works	Indication	How is it taken?
Evista* (raloxifene)	Acts like estrogen in the bones: promotes the building of new bone	Treatment of osteoporosis in postmenopausal women	Oral tablet taken once daily
Calcitonin	How it works	Indication	How is it taken?
Miacalcin NS* (salmon calcitonin)	Reduces the removal of calcium from bone in conditions with an increased rate of bone resorption such as osteoporosis thereby increasing bone density	Treatment of osteoporosis in women greater than 5 years postmenopausal with low bone mass relative to healthy premenopausal females	Nasal spray taken once daily
PTHs	How it works	Indication	How is it taken?
Forteo* (teriparatide)	Builds new bone formation by stimulating bone building cells, thereby increasing bone density	Treatment of postmenopausal women with severe osteoporosis who are at high risk of fracture or who have failed or are intolerant to previous osteoporosis therapy To increase bone mass in men with primary or hypogonadal severe osteoporosis who have failed or are intolerant to previous osteoporosis therapy. The effects on risk for fracture in men have not been demonstrated. For the treatment of osteoporosis associated with sustained systemic glucocorticoid therapy in men and women who are at increased risk for fracture	Subcutaneous (under the skin) injection into thigh or abdominal wall, once daily

*All brand names and trade-marks are the property of their respective owners

Important Safety Information

All treatments can cause side effects. Please see below for a list of common side effects by treatment class and always consult your doctor about any treatment option you may be considering.

RANK Ligand Inhibitor – Common side effects include: Pain in your muscles, arms, legs or back; skin condition with itching, redness and/or dryness (eczema). May also cause skin infection with a swollen, red area of skin that feels hot and tender and may be accompanied by fever (cellulitis); lower blood calcium (hypocalcemia).

Bisphosphonates – Common side effects include: Pain in your muscles and/or joints; abdominal pain, heartburn, nausea. Oral bisphosphonates may also cause ulceration of the esophagus. Bisphosphonates delivered by infusion may also cause low blood calcium (hypocalcemia); worsening of kidney function.

Hormone Replacement Therapy – The Women's Health Initiative assessed the benefits and risks of oral combined estrogen plus progestin therapy and oral estrogen-alone therapy compared with placebo (a pill with no active ingredients) in postmenopausal women in a large clinical study.

The WHI trial indicated an increased risk of myocardial infarction (heart attack), stroke, breast cancer, pulmonary emboli (blood clots in the lungs) and deep vein thrombosis (blood clots in the large veins) in postmenopausal women taking oral combined estrogen plus progestin.

The WHI trial indicated an increased risk of stroke and deep vein thrombosis in postmenopausal women with prior hysterectomy (surgical removal of the uterus) taking oral estrogen-alone.

SERMs – Common side effects include: Hot flashes, leg cramps and flu-like symptoms. May also cause blood clots in the veins.

Calcitonin - Common side effects include: Sore nose, runny and stuffy nose (rhinitis), nasal dryness with crusting, non-severe epistaxis, inflammation of the sinuses (feeling of pressure or pain in nose, cheeks and behind eyes), sneezing, nasal allergy, irritated nose, nasal odour, swelling, redness and damage of the mucus lining of the nose. May also cause fatigue, dizziness and disturbed vision, which may impair your reactions.

PTH - Common side effects include: Dizziness, nausea; pain in and around joints and leg cramps. As part of drug testing, teriparatide, was given to rats for a significant part of their lifetime. In these studies, teriparatide caused some rats to develop osteosarcoma, a bone cancer. The potential to cause osteosarcoma in rats was increased with higher doses and longer periods of treatment. Osteosarcoma in humans is a serious but very rare cancer. Osteosarcoma occurs in about 4 out of every million people each year. None of the patients in the clinical trials or post-treatment follow up developed osteosarcomas. Osteosarcoma has been reported rarely in people who took the prescription drug. It is not known if people who take the drug have a higher chance of getting osteosarcoma You should discuss any safety concerns you have about the use of this product with your doctor.