Welcome to episode #5 of the bone coach podcast…this podcast is all about osteoporosis medications and helping you understand the side of these drugs that's often minimalized, rushed, or not brought to your attention. My goal by the end is for you to be more informed about the risks, side effects, and implications of short and long term use of osteoporosis medications. In this episode, you'll learn...

• A quick refresher on bone remodeling and what cells are involved in that process

• An overview of the different types of osteoporosis medications, the drug names, what they do, and the associated risks, side effects, and short and long term implications of drug use. (This is at a high level. I’m not going to go into too much detail on each individual drug.)

• Important considerations regarding osteoporosis medications

• How I reached my decision to forgo them

• Why diet, lifestyle, proper supplementation, and exercise are all going to be key for improving your bone health, regardless of the choice you make.

Episode Timeline

06:20: Review of bone remodeling. Osteoporosis drugs interfere with this process.

07:29: 1st category of Osteoporosis Drugs: Anti-Resorptives

07:48: Anti-Resorptive #1: Bisphosphonates

10:40: Long term use of bisphosphonates. Safety concerns. Bone quality.

11:14: Anti-Resorptive #2: RANK-L Inhibitors (Prolia)

13:55: Other Anti-Resorptives: Calcitionin, Hormone & Estrogen Therapy

15:03: 2nd category of Osteoporosis Drugs: Anabolic Agents

15:30: Anabolic #1: Sclerostin Inhibitor (Evenity)

17:20: Anabolic #2: Parathyroid Hormone Analog (Forteo)

19:30: Anabolic #3: Parathyroid Hormone Related Protein (Tymlos))

20:45: Review of drugs discussed with example and important considerations

21:55: Use this information as a way to become informed and empowered

22:28: How I reached my decision to forgo OP drugs

24:50: Figuring this out for yourself

26:45: Diet, lifestyle, proper supplementation, exercise are all key for bone health

Resources Mentioned:

--->Claim your FREE 7-Day Osteoporosis Kickstart here!

Citations for each of the drugs mentioned during the podcast included throughout the full transcript below.

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Full Transcript:

Welcome, welcome to episode #5 of the bone coach podcast…

Now, this podcast is a bit different.

If you’ve listened to episodes 1-4 then you’ve already heard about my own journey to being diagnosed with osteoporosis. You’ve learned about our bones, how they build up and breakdown and what cells are involved in that process. You’ve learned about causes of osteoporosis. And you’ve also learned about the importance of understanding if you’re actively losing bone…

But there’s an important question still that I’ve yet to address…

Should I take osteoporosis drugs?

If you’re newly diagnosed with low bone density or osteoporosis, you may have heard your doctor mention osteoporosis medications...and you may be wondering, like I did, if those osteoporosis drugs should have a part in improving your bone health.

When I was first diagnosed, my immediate, visceral reaction was “how do I fix this right now”...it was almost like the convergence of an impending sense of doom, a desperate scramble to secure my future, and this the desire to find hope...somewhere...anywhere.

And you may have be having those feelings too.

They’re normal.

And as soon as you start looking for solutions to overcome the doom, to secure your future, to find your hope, and to fix your low bone density, one of the first things you’ll come across, either by way of your own research, or through a conversation with you doctor, are osteoporosis medications.

These are medications that alter the normal bone remodeling process to either increase or decrease the activity of the cells responsible for building up or breaking down bone.

These drugs may be presented to you as the key to improving your bone health…

But what I want to remind you is that there are no magic bullets and no quick fixes for improving your bones.

Have you ever heard of the saying “there’s no such thing as a free lunch?”

It’s an old economic adage that comes to my mind that simply put means:

You don't get something for nothing. There is cost to the decisions we make.

This cost comes in the form of side effects and the short and long-term implications of using any medication including osteoporosis drugs.

Often times, that cost, the side effects and the short and long term implications of drug use, along with the information you need to make a fully informed decision, are brushed over, minimalized, or they’re rushed…

Because you’ll hear about the benefits, or what could happen if you don't take them... but there’s also another side of the story.

And in order to be empowered when making your decision, I want to make sure you understand what that cost can be...what are the side effects...what are the short and long term implications of drug use.

Because these are powerful drugs that have a dramatic effect on bone physiology.

It’s not like taking an aspirin...and the long term implications of the use of these drugs, in many cases, are still not known.

So, I would implore you to avoid making drastic or quick decisions without first researching and understanding them thoroughly…

For me, after taking my circumstances into account, learning about the osteoporosis drugs on the market along with their side effects, I made the decision not to use any osteoporosis medications and instead opted to focus on optimizing diet, lifestyle, supplements, exercise, and other areas of my life as the means for improving my bone health.

Now, we’re all different. Our circumstances are different. Yours are different than mine. Mine are different than the next persons…

So I’m not here to pass judgement no matter what you decide. I’m hear to educate you. I’m here to empower you. I’m here to support you.

And that starts with information...and, specifically, providing you with the “other” side of the picture that’s so often brushed over.

In this episode, I’m going to:

• Give you a quick refresher on bone remodeling and what cells are involved in that process

• I’m going to give you an overview of the different types of osteoporosis medications, the drug names, what they do, and the associated risks, side effects, and short and long term implications of drug use. (This is at a high level. I’m not going to go into too much detail on each individual drug.)

• I’ll share some important considerations regarding OP meds

• I’ll talk about how I reached my decision to forgo them

• Then I’ll touch on why diet, lifestyle, proper supplementation, and exercise are all going to be key for improving your bone health, regardless of the choice you make.

Here’s what I’m not going to do - I'm not going to tell you whether you should or should not take osteoporosis drugs. That's not my place, and I don't know your individual circumstances.

But, with the information I’m going to share here, you’ll be better informed when making that decision for yourself.

Last thing, before we really dive into the episode, you can find all of the detailed show notes, full transcript, and resources mentioned in the episode over at bonecoach.com/osteoporosis-medications

Review of bone remodeling

I go into a little more detail on this process in episode #2, but here’s a quick summary of bone remodeling…

Bone remodeling is a process that occurs throughout our entire lives and balances bone resorption and bone formation.

This process helps us:

• Regulate calcium balance

• Repair microscopic cracks in bone

• Helps us create new, stronger bones

• Heal fractures if and when we get them

In this process, there are really three major players or bone cells involved.

You have the osteocytes that sense the damage and communicate to the other cells that repair is needed. You have the osteoclasts that come in, and chew up or excavate the damaged bone. Then you have the osteoblasts that follow and build the new bone. ¹

Osteoporosis drugs alter or interfere with this normal bone remodeling process.

Different types of osteoporosis medications

Really there are two basic categories of osteoporosis drugs and they are separated by how they work.²

*This is not an exhaustive overview.

Anti-Resorptives

How they work

Antiresorptive drugs work by slowing the resorption part of that bone remodeling process. They reduce the rate of the breakdown of bone tissue. This also indirectly leads to a reduction in new bone formation.The first type of anti-resorptive drugs are...

Bisphosphonates

Bisphosphonates reduce bone breakdown by preventing osteoclasts from removing bone. This may very well be one of the first medications you hear about or come across.

What they won’t do

Now, yes, bisphosphonates will reduce bone resorption. But here’s what they won’t do…

They won’t stop inflammatory processes taking place in your body that could be contributing to bone loss. So if you have widespread chronic inflammation from some underlying condition, or autoimmune disease, or factors related to diet and lifestyle, in your body, that’s not something bisphosphonates will fix.

They won’t cure the underlying causes of active bone loss.

For example, if you have primary hyperparathyroidism, and you have a small tumor on one of your parathyroid glands that is increasing PTH and in turn increasing bone resorption...Taking a bisphosphonate will not cure the tumor causing the increase in PTH.

All these bisphosphonates are really doing is preventing osteoclasts from resorbing bone.

Drug Names

Alendronate (Fosamax®, Binosto®), Ibandronate (Boniva®), Risedronate (Actonel®, Atelvia™), Zoledronic Acid (Reclast®)

How they are administered

Ranges anywhere from oral tablets taken daily, weekly, or monthly to injections that happen every few months to a year. With these medications come certain risks and side effects that aren’t always addressed or discussed up front...

Risks and side effects

I’m listing these straight off of the National Osteoporosis Foundation website. Side effects of bisphosphonates may include:

• Bone, joint or muscle pain

• Nausea

• Difficulty swallowing

• Heartburn

• Irritation of the esophagus

• Gastric ulcers

• IV bisphosphonate could cause flu-like symptoms, fever, headache and pain in muscles or joints

• Can affect kidney function

• Bisphosphonates will worsen low blood calcium levels.

• Can also negatively interact with minerals like calcium, magnesium, and others if taken too close together.

• Osteonecrosis of the jaw (ONJ). This occurs when the jaw bone begins to starve from a lack of blood. Basically, you have cells in the jaw bone that start to die.

• Atypical fractures of the upper femur (the bone right in the middle of your thigh) ^{3 4 5}

One of the greatest concerns of bisphosphonates for treating osteoporosis is that the data about the safety and efficacy of these drugs are from patients who took them for less than 5 years.

Reports of adverse effects with prolonged use have caused concern about the long-term safety of bisphosphonates ⁶ ...and I can only imagine that the information here with continue to evolve in the coming years.

Last thing I’ll point out before moving on to the next type of anti-resorptive drug, is that there is also evidence that suggests that even though bisphosphonate therapy is effective at reducing bone breakdown, longer-term, this may also cause microcrack accumulation, which could ultimately lead to a loss of structural integrity and strength in the bone.

What does that mean?

It means long-term bisphosphonate use could lead to the retention of too much of that old, damaged bone which in turn could lead to poor bone quality.⁷

RANK ligand (RANKL) inhibitor

The next drugs we’re going to talk about are RANK Ligand Inhibitors. This would be your Denosumab also called Prolia or XGEVA. These are still anti-resorptives, so it’s preventing bone from being broken down, but it’s doing so through a different mechanism of action.

Drug Names

Denosumab (Prolia, XGEVA)

How They Work

Here’s a simplified version of how this works. Osteoblasts and other bone cells produce a protein called RANK Ligand. RANK-L is like the message “sent” from osteoblasts to osteoclasts to “tell” them to break down bone. When these osteoclasts receive the “message,” they become activated and start to resorb bone. So, osteoclasts need RANK Ligand in order to be activated, function, and survive. What these RANK Ligand inhibitors do (what Prolia does), is binds to RANK Ligand and prevents the osteoclast from receiving the “message” to become activated and start breaking down bone.

So the end goal of reducing osteoclast activity is still the same as it is with bisphosphonates, it’s just done through a different mechanism.

Risks & Side Effects

Now, I’m reading these side effects to you right off of the Prolia drug website^8:

• Back, arm, leg, and muscle pain

• Elevated cholesterol

• Bladder infection

• Serious allergic reactions

• Low blood calcium (hypocalcemia)

• Osteonecrosis of the jaw

• Unusual thigh bone fractures.

• Skin problems like dermatitis, rash, and eczema

• Increased risk of serious infection (those that require hospitalization)⁹

• It can affect the body’s ability to fight infections and can cause serious infections in your skin, lower stomach area (abdomen), bladder, or ear.

• It can also cause inflammation in the inner lining of the heart (endocarditis).

• It can increase your risk of broken bones, including broken bones in the spine, after stopping Prolia®...I’m reading this verbatim, “After your treatment with Prolia® is stopped, your risk for breaking bones, including bones in your spine, is increased. Your risk for having more than 1 broken bone in your spine is increased if you have already had a broken bone in your spine. Do not stop taking Prolia® without first talking with your doctor.”

• “It is not known if the use of Prolia® over a long period of time may cause slow healing of broken bones.”

So, there are some pretty serious potential side effects and unknowns here with the use of Prolia that you need to be aware of.

Those are the two primary anti-resorptive treatments that we’re focusing on in this podcast, Bisphosphonates and RANK Ligand Inhibitors, but there are others that include:

• Calcitonin: Calcitonin is a natural hormone produced by our bodies to lower blood calcium levels by suppressing osteoclast activity in the bones and increasing the amount of calcium excreted in the urine. Calcitonin opposes the effects of parathyroid hormone (PTH), which acts to increase the blood calcium level. In medication form, Calcitonin is a synthetic hormone that’s involved in calcium regulation and bone metabolism.

• Estrogen Therapy or Hormone Therapy: involves the use of either estrogen by itself or estrogen combined with progesterone, sometimes testosterone. In the future, I’ll be doing an entire episode with a hormone expert on estrogen and hormone therapy, and bio-identical hormones.

• Selective Estrogen Receptor Modulators (SERMs): These are synthetic molecules that have the ability to bind to estrogen receptors throughout the body and act as estrogen agonists or antagonists.

• Tissue Specific Estrogen Complex (TSEC)

Those are the other Anti-resorptives drugs but the ones I’m mainly focused on in this episode are the bisphosphonates and RANKL inhibitors because those are the ones that will likely be discussed first.

Now, the next category of osteoporosis drugs are called...

Anabolic Agents

Anabolics work by stimulating the formation part of the bone remodeling process. They’re stimulating the cells that build bone, the osteoblasts, to make more bone, and make it faster.

More bone ends up being formed than is taken away.

Usually the people who are recommended these drugs are those who have recently had low or no trauma fragility fractures.

The first type of drug in this anabolic category is...

Sclerostin Inhibitor

Drug Name

Romosozumab-aqqg (Evenity)

How It Works

Evenity is a monoclonal antibody that works by inhibiting a protein called sclerostin. Sclerostin stops bone production and increases bone breakdown. So, by inhibiting sclerostin, bone formation increases and bone resorption decreases. ¹⁰ It's building more bone than is being broken down. This is done through a monthly injection.

Risks & Side Effects

Now, as of the time of this recording in November of 2019, this is still a newer drug, so this list could still continue to evolve, but here are the current list of side effects noted directly on the Evenity website^11:

• Headaches

• Joint pain

• May increase the risk of myocardial infarction (heart attack)

• May increase the risk of stroke and cardiovascular death

• Hypersensitivity reactions, including angioedema (rapid swelling beneath the skin), erythema multiforme (bullseye shaped lesions), dermatitis, rash, and urticaria (hives)

• Hypocalcemia (low blood calcium)

• Osteonecrosis of the Jaw (ONJ) - jaw bone tissue dying due to lack of blood supply.

• Atypical low-energy or low trauma fractures of the femur

Those are the risks and side effects. Now, I’m quoting this next part about Evenity right off the FDA’s website:

“After EVENITY discontinuation, BMD returns to approximately baseline levels within 12 months in the absence of follow-on antiresorptive therapy.”¹²

So, what that’s saying is, you would be on Evenity for a year, which is the duration of the treatment. Then, you would need to immediately follow Evenity with one of the bisphosphonates, just to not lose the bone you’ve just gained.

The next anabolic drug is a...

Parathyroid Hormone (PTH) Analog

Drug Name

Teriparatide - Forteo®

How It Works

Forteo is a synthetic form of Parathyroid Hormone (PTH). We produce PTH naturally to help regulate calcium levels in the blood and to help convert Vitamin D to its active form.

Normally, when PTH is elevated, this will increase the activity level of osteoclasts to release calcium from the bones into the blood. However, when PTH is elevated intermittently as it is with daily injections of Forteo, this can stimulate your osteoblasts to build more bone than is being broken down.

Basically, your osteoblasts are building up more bone than your osteoclasts are breaking down.

But there are risks and side effects that come with this...

Risks & Side Effects

• Dizziness

• Palpitations

• Nausea

• Increase in blood calcium (hypercalcemia)

• Increase in urine calcium (hypercalciuria)

• Cramps and muscle aches

• In rat studies some of the rats developed osteosarcoma which are malignant bone tumors.

• There is also a warning for people who have Paget’s disease, people with unexplained Alkaline Phosphatase elevations, people who have had radiation treatments involving the skeleton, hyperparathyroidism, those with cancer that has spread to the bone, and people with elevated blood calcium levels, there’s an additional warning for them.¹³

I also want to point out that right on the National Osteoporosis Foundation website, it says and I quote “this drug can only be taken for a maximum of two years. At the end of two years, bone loss can be rapid. In order to retain the benefits of treatment with teriparatide, most experts recommend that patients start an antiresorptive medicine right after finishing the teriparatide therapy.”

So, just like with Evenity, you would immediately need to follow Forteo with the use of another drug...and it would be one of those antiresorptives I mentioned earlier (Bisphosphonates or RANK-L Inhibitors)...and those drugs have their own side effects and timelines for use.

The next drug that’s very similiar to Forteo is...

Parathyroid Hormone-Related Protein (PTHrp) Analog

Drug Name

Abaloparatide - Tymlos

How It Works

Its similiar to Forteo in that again it’s an anabolic agent and it stimulates more bone-building than bone breakdown, but it uses a Parathyroid Hormone Related-Protein and it’s only used on women.

This drug still comes with many of the same risks and timeline for use.

Risks & Side Effects

• Hypercalciuria (excessive calcium in urine)

• Dizziness

• Nausea

• Headache

• Palpitations

• Fatigue

• Upper abdominal pain

• Vertigo

• Again, in rats, it caused an increased risk of osteosarcoma (a malignant bone tumor). It’s unknown if the same effect applies to humans.

• Now this is directly off of the Tymlos website, “Because of the unknown findings in humans, cumulative use of TYMLOS and parathyroid hormone analogs (e.g., teriparatide) for more than 2 years during a patient’s lifetime is not recommended.¹⁴

That’s a quick summary and overview of Tymlos and its risks and side effects.

So, I want to just pause and review this for a minute because we’ve just introduced a lot of new drugs, we talked about side effects, and we also talked about having to follow one drug with the use of another drug.

Let’s just use an example here.

Say I use one of the anabolics, Evenity for 12 months, or Forteo or Tymlos for 2 years, which as you just heard, use beyond 2 years in your lifetime is not recommended.

Then I need to immediately follow these drugs with an anti-resorptive to avoid as I quoted earlier “rapid bone loss.”

If that anti-resporptive is a bisphophonate like Fosomax or one of the others...the safety and efficacy of bisphosphonate drugs for treating osteoporosis are from patients who took them for less than 5 years.

Adverse effects reported with prolonged use of bisphosphonates has caused concern about their long-term safety.

We also talked about how long-term bisphosphonate use could also lead to the retention of too much of that old, damaged bone which in turn could lead to poor bone quality.

If that anti-resorptive is not a bisphosphonate and it’s Prolia, we already know that Prolia has a long list of side effects and that it can, and I quote, “increase your risk of broken bones, including broken bones in the spine, after stopping Prolia.”

Remember, I’m sharing this with you not to scare you... because I don’t like when people use fear as an emotional trigger to get me to take action on things. Nobody likes to be induced into a state of anxiety, myself included.

I’m sharing this with you to put some of this into perspective and to educate and empower you… because you’re going to hear about the benefits, or what could happen if you don't take them... I want you to have the side of the picture that I feel is glossed over and often times minimalized.

So, especially when you’re younger, in your 30’s like I am, your 40’s and 50’s you want to think about the long term also.

When I was coming to my decision on forgoing osteoporosis medications, these are some of the things I was thinking about and taking into account...

Why I decided to forgo osteoporosis medications

• My DEXA scan results. The worst score I had seen in my L4 was a -3.4 with greater bone density found in the vertebrae going up my spine.

• No fractures

• I was taking my age, being in my early 30’s, into consideration.

• I had at least a very general sense of what could have possibly contributed to my osteoporosis, which I talk about in depth in episode 1...autoimmune disease, poor gut health, hormone issues, medications, toxins, high stress, poor sleep, those are just a few. I certainly didn’t have all the answers. I still don’t have all the answers, because just like you I’m learning every single day.

• I consulted with a variety of different people...some had helpful information. Some didn’t.

• I did some reading and research on the side effects of certain bone drugs and treatments and, ultimately, I decided that wasn’t the path for me.

• My mindset and past experiences with medical care played a major role in my decision. Even though I struggled through all of these health challenges, I really didn’t want to take medication. Not for a week. Not for a year. Not for 5-10 years. Not for a lifetime.

• Because I had gone that route before. For the great majority of my life, I believed that the solution to what ailed me was at the pharmacy…when I had pain in my joints and knees and lower back, I’d reach for 800mg Ibuprofen or pain killers multiple times a day. I took Proton Pump Inhibitors to unnecessarily suppress my stomach acid. I took sleeping pills, antidepressants, antibiotics, and countless other medications to help address signs and symptoms of conditions without ever addressing the underlying cause. I temporarily received the benefits, along with the side effects, but I never received complete resolution of those issues because I was just covering up the cause.

• Eventually that led to a disenchantment with the type of medical care I was accustomed to, and really I just wanted to divest myself from thinking that the solution to my health was in a pill.

• That was my personal journey and thought process...

• I’m not saying medications don’t have their place...because in some cases they do...but what I came to realize was that for me, the solution was not osteoporosis drugs.

As you’re figuring this out for yourself, you may find yourself following a similar path as I did:

• Thinking about your personal fracture risk?

• Have you already had low or no trauma fragility fractures?

• How advanced is your osteoporosis?

• Do you know the underlying cause? Go listen to Episode #3 on Osteoporosis Causes if you’re still trying to figure this out.

• Are you still actively losing bone? If so, that needs to be addressed.

• You might be taking your age into consideration

• The drug side effects...remember there’s no such thing as a free lunch. There’s a cost to everything.

• The commitment you would be making both now and in the future. Remember, once you start one drug, you’ll likely have to follow it with another. The gains you make on bone don’t come with a lifetime guarantee.

• There are a lot of unknowns with the long-term use of these drugs.

Look, ultimately it will be you, the educated, empowered, informed patient, who makes the decision on whether or not you should start treatment with osteoporosis drugs.

If you decide that even after taking the side effects and short and long term implications of drug use into account that these drugs are still the right choice for you, that’s okay. And for what it’s worth, I support your decision, because I don’t know your specific circumstances…

But regardless of what you decide, there are still some key areas that you need to focus on improving regardless of whether you’re on bone medications or not.

Making improvements to diet, lifestyle, supplementation, exercise and other areas of your life that will all be key for your bone health. That's really what I help people figure out.

As I mentioned before you can find all of the show notes, the resources mentioned, and a full transcript of this episode over at bonecoach.com/osteoporosis-medications

That’s it for this one... I’m your Bone Coach, Kevin Ellis. See you in the next episode.