Osteoporosis medications — the treatment that takes years to evaluate

This article is for informational purposes only and does not constitute medical, legal, or financial advice. Please consult appropriate professionals for guidance specific to your situation.

The thing about osteoporosis medication is that you take it for years without any obvious effect. Your parent swallows a pill every morning or gets an injection once a year, and then what? Nothing visible happens. Their bones aren't obviously stronger. They don't feel different. There's no immediate payoff like there is with blood pressure medication, where you can measure lower numbers. With osteoporosis medication, you're investing in prevention. You're hoping that in five or ten years, your parent won't break their hip, but you won't know if the medication made the difference until something either happens or doesn't.

This makes osteoporosis medication tricky. Your parent needs to want to prevent a fracture badly enough to take medication for years. They need to be willing to deal with side effects that might develop. They need to commit to something where the benefit is invisible and years away. Some people can do this easily. Some people give up after a year or two because they don't see the point. And sometimes, your parent is actually right to question whether treating osteoporosis makes sense for their particular situation.

Osteoporosis means the bones are less dense, more fragile, more likely to break. The risk of fracture increases with age, especially for women after menopause. A bone density test, or DEXA scan, measures how dense the bones are and predicts fracture risk. But the DEXA scan is not a crystal ball. It tells you your parent's fracture risk, but it doesn't tell you whether preventing a fracture is worth the costs of treatment. That's a different question, and it depends on your parent's health, their life expectancy, their values, and their ability to tolerate medication side effects.

Whether to Treat

Before deciding to treat osteoporosis, consider your parent's actual fracture risk. Someone who's 95 years old and frail might not benefit from osteoporosis medication because the treatment takes years to show benefit, and your parent might not have years. Someone who's 65, healthy, and relatively mobile might benefit from treatment because they have years of life ahead and preventing a hip fracture is worth doing.

The type of bone loss matters. Some people have osteoporosis mostly in the hip. Some have it mostly in the spine. Some have it everywhere. Fracture risk is related to bone density but also to bone quality, balance, and fall risk. Your parent might have low bone density but also excellent balance and low fall risk, in which case treatment might not be urgent. Your parent might have less severe bone loss but also poor balance and high fall risk, in which case treatment matters more because a fall is more likely.

Your parent's medical stability is important. If they've recently had a heart attack or stroke, or they have advanced cancer or another serious illness, starting long-term osteoporosis treatment might not make sense. Treatment is for people with enough health and life expectancy to benefit from fracture prevention.

The psychological aspect matters too. If treating osteoporosis will reduce your parent's anxiety about breaking bones, allowing them to move more freely and live more actively, that's valuable. If treatment causes such severe side effects that your parent becomes depressed or anxious, that's harmful. The goal is your parent's quality of life, not a DEXA score.

The Options

Bisphosphonates like alendronate, risedronate, and zoledronic acid are old and commonly used. They slow bone loss. They need to be taken on an empty stomach with a full glass of water, with the person sitting upright for 30 minutes afterward. If you don't do this, they can cause severe damage to the esophagus. Your parent swallows weekly or monthly or gets an infusion once a year depending on the medication.

Side effects of bisphosphonates include nausea, heartburn, joint pain, and in rare cases, dead jaw bone (osteonecrosis of the jaw). The osteonecrosis risk is highest with the intravenous bisphosphonates, and especially in people having dental work. Your parent's dentist needs to know they're on bisphosphonates before doing extensive dental work.

Denosumab is a newer medication that works differently, blocking a signal that tells bone cells to break down bone. It's given as an injection under the skin twice yearly. Some people tolerate it better than bisphosphonates. But stopping denosumab can cause rapid bone loss, so it's usually a longer commitment.

Calcium and vitamin D are not glamorous medications but they're important. Your parent's bones need calcium and vitamin D to be strong. If they're deficient in either, no osteoporosis medication will work as well. Your parent should get adequate calcium from diet or supplementation, usually 1000 to 1200 mg daily depending on age. Vitamin D is important too, with most older adults recommended 800 to 1000 IU daily. Some need more if they're deficient.

Hormone replacement therapy can help bone density in women going through menopause or in the years right after. But hormone therapy carries other risks, and it's usually not used as a primary osteoporosis treatment anymore. Some women benefit from it for bone health as a side benefit of using hormone therapy for other reasons, but it's not commonly recommended for osteoporosis alone.

Teriparatide is a medication that actually stimulates bone formation rather than just slowing bone loss. It requires daily injections and is usually used in severe osteoporosis or when other medications haven't worked. It's expensive and requires regular monitoring.

Drug holidays are an interesting concept. Your parent takes bisphosphonates for a few years, then stops for a year or two. The medication stays in the bones for a long time after stopping, so bone density doesn't immediately decline. Drug holidays reduce the cumulative dose and reduce rare side effects that come from long-term use. Whether your parent needs a drug holiday depends on their fracture risk, their bone density trend, and how many years they've been on medication. This is a conversation with their doctor.

Living With the Treatment

Compliance with osteoporosis medication is challenging because the medication causes no immediate benefit, and the side effects are obvious and immediate. Your parent takes alendronate and has heartburn or nausea. That's today's problem. The prevention of a hip fracture is years away and invisible. Of course your parent might think the medication isn't worth it.

Finding a regimen that your parent can actually tolerate is important. Some people can't do the special instructions for bisphosphonates—sitting upright, empty stomach, water. For them, the intravenous bisphosphonate given once a year might be better. Some people don't tolerate that. Finding something your parent will actually take is better than the theoretical perfect medication that they stop after a month.

Dental care needs special consideration. If your parent is on bisphosphonates or denosumab, they need to tell their dentist before any extensive dental work. They might need preventive antibiotics. They might need to pause medication before and after major dental work. Good dental care is still important but needs to be coordinated with osteoporosis treatment.

Fall prevention is as important as medication. Your parent with strong bones who falls and breaks their hip is just as disabled as your parent with weak bones who falls and breaks their hip. Actually, preventing the fall matters more than the medication. Keeping your parent's environment safe, making sure they wear appropriate shoes, making sure they have grab bars in the bathroom, making sure they have adequate lighting, all of this matters as much as medication.

Exercise builds bone strength. Weight-bearing exercise and resistance training can slow bone loss and maintain balance. Your parent should be moving regularly, doing something that stresses the bones, doing balance training. Medication plus exercise is better than medication alone.

Your parent might take osteoporosis medication for years and never know if it worked because they never broke a bone. That might be because the medication worked. It might be because they have good balance and low fall risk. It might be because they were never going to break a bone anyway. Nobody knows. But if your parent is at real risk, if they're willing to take the medication, if they can tolerate it without serious side effects, preventing a hip fracture is worth doing. The key is making sure your parent actually wants to treat it, not just that their doctor recommended it.

How To Help Your Elders provides educational content for family caregivers. This is not a substitute for professional medical, legal, or financial advice. Every family situation is different — what works for one may not work for another.