Tips to help you stay on track with your osteoporosis treatment

If you have osteoporosis or are at risk for it, what would you do if your doctor recommended a safe and effective elixir that’s been proven to slow bone loss, restore bone density, strengthen bone, and help reduce the risk of fractures? You’d take it, right? Most people would, considering the pain, expense, and disability associated with fractures in the spine and hip—two areas that are particularly vulnerable to fractures resulting from osteoporosis.

That elixir is a class of medications known as bisphosphonates, which includes alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), and zoledronic acid (Reclast).

But many people who would benefit from this treatment fail to take the medication as prescribed—even those who’ve been diagnosed with osteoporosis and have already suffered a fracture. In fact, according to a study from the Archives of Internal Medicine, about 45% of women who were prescribed osteoporosis medication (half of them were on bisphosphonates) stopped taking the drugs within the first year of treatment; after five years, the rate of non-adherence increased to 52 percent.

What’s Going On Here?

The main problem, according to doctors and their patients, is the effect that bisphosphonates have on the stomach and intestines. Oral bisphosphonates are not easily absorbed, and they can lead to gastrointestinal side effects such as indigestion, diarrhea, stomach pain, heartburn, nausea, and peptic ulcers (non­ healing defects in the stomach or small intestine) as well as muscle cramps.

The nature of osteoporosis is another factor that contributes to bisphosphonate non-adherence. A stealthy condition with no out­ ward symptoms, osteoporosis progresses painlessly (until there is a fracture). With no physical complaints to speak of, people with osteoporosis may feel less compelled to take their medication regularly than, say, people who are taking drugs for the relief of severe pain.

A third factor, oral bisphosphonates are not easy to take. For the best results, they must be taken immediately after getting up in the morning, at least half an hour before eating or drinking anything besides water (even tea, coffee, fruit juice, or mineral water can interfere with their absorption), and before taking any other medication. Also, you must drink at least 8 oz of water to wash down the tablet and sit or stand upright for at least 30 minutes afterward.

Last, the cost of bisphosphonate drugs is another concern that keeps some people from taking their medication as pre­scribed. Even though one of these drugs is available as a low-­cost generic, the fact that they need to be taken over a long period of time can discourage some people, particularly those with limited incomes.

The Costs of Non-adherence

While the discomfort, inconvenience, and expense of bisphosphonate medications contribute to a high rate of non-adherence, the costs of discontinuing osteoporosis treatment may be even higher. People who take their bisphosphonate treatment as prescribed, according to a five­year study published in the Mayo Clinic Proceedings, have a 20 to 45 percent lower risk of fractures. And the more closely they adhere to the prescribed medication regimen, the lower the fracture risk.

In another study, published in 2009 in the Journal of Bone and Mineral Research, a simulation model was developed to assess the effect of bisphosphonate therapy on fracture rates in women over age 50 with osteoporosis. Treatment involved either daily or weekly Actonel or Fosamax. Researchers found that boosting adherence to “optimal” (taking 90 percent or more of prescribed doses) from “usual” (the current rate of adherence in the United States) would prevent 258 fractures per 1,000 women over their lifetime.

The additional medication needed to reach this level of adherence would cost an average of $3,800 per woman, but would save an average of $2,100 per woman in fracture­-related costs, making bisphosphonates a low-­cost way ($1,700) to reduce fractures.

Strategies To Improve Adherence

A number of strategies have proven successful at increasing adherence to bisphosphonate medications.

Minimize the risk of side effects. To reduce the risk of gastrointestinal side effects with an oral bisphosphonate be sure that you take it in the morning on an empty stomach with a 12 ­oz glass of water while standing or sitting in an upright position. For 30 minutes afterward, do not lie down or eat or drink anything other than water. Your doctor may also prescribe other medication to reduce or eliminate gastrointestinal side effects.

Reduce the dosing frequency.

Dosing regimens that are less frequent can help with the inconvenience of once-­a­-day oral bisphosphonates. Once­weekly regimens of Fosamax or Actonel appear to be just as effective and may minimize the risk of gastrointestinal side effects. Actonel and Boniva are available in a tablet that can be taken once a month.

Switch to another formulation.

If you still cannot tolerate oral forms of bisphosphonates because of the side effects, two intravenous (I.V.) forms are available: I.V. Boniva, which is given every three months, and I.V. Reclast, which is given once a year or once every two years. However, I.V. bisphosphonates are more expensive than the oral formulations and can cause short-­lived flu­like symptoms.

Another I.V. bisphosphonate is pamidronate (Aredia). Although this drug has not been approved by the U.S. Food and Drug Ad­ ministration (FDA) for the treatment of osteoporosis and limited data on fracture reduction have been published, it has been shown to improve bone mass.

Lower your costs.

If cost is a factor, there is an inexpensive, generic form of Fosamax known as alendronate. It is available in the weekly dose.

The Bottom Line

Communication and cooperation with your doctor are the keys to the successful prevention and treatment of osteoporosis. If you’re not taking your medication as prescribed, don’t conceal it from the doctor. Instead, have an open and honest conversation about what is keeping you from following your prescribed regimen—whether it is the side effects, cost, or inconvenience or you just do not think the medication is having any effect on your bone health.

Once your doctor is aware of the issues, she or he can help identify the right medication for your specific needs.

Publication Review By: Lee H. Riley III, M.D., and Suzanne M. Jan de Beur, M.D.

Published: 18 Nov 2011

Last Modified: 05 Feb 2015