Management Guidelines

Treatment Recommendations – Prescription Medications, Nutrition & Supplements, Physical Activity

Bisphosphonates

Bisphosphonates are a family of drugs used to treat osteoporosis. There are four bisphosphonates currently approved for use in Canada: alendronate (Fosamax ®), etidronate (Didrocal ®), risedronate (Actonel ®) and zoledronic acid (Aclasta ®). Also available are: Actonel DR ® and Fosavance ® (Fosamax ® with vitamin D). Generic versions are also available.

How do they work?

Bisphosphonates bind to the surfaces of the bones and slow down the bone resorbing action of the osteoclasts. This allows the osteoblasts to work more effectively.

How effective are they?

All four bisphosphonates increase bone density and prevent vertebral fractures. Alendronate, risedronate and zoledronic acid have also been shown to prevent hip and non-vertebral fractures.

Who can take them?

Bisphosphonates are used to treat osteoporosis in: postmenopausal women and in men; and in men and women of any age who are using steroid medications.

How are they taken?

Bisphosphonates have very specific instructions about how they must be taken in order to be absorbed properly and avoid side effects. Because calcium interferes with the absorption of bisphosphonates, calcium supplements must be taken at other times of the day. See details on Osteoporosis Canada website.

Are there side effects?

The most common side effects are nausea, abdominal pain and loose bowel movements. Bone, joint and/or muscle pain has been infrequently reported in patients taking bisphosphonates. There is a small risk of ulcers in the esophagus with both alendronate and risedronate, especially if taken incorrectly.

The most common side effects of zoledronic acid, which usually only last a day or two, are fever, pain in the muscles, bones or joints and headache. There have been rare cases of acute renal dysfunction following infusion of zoledronic acid.

In very rare cases, alendronate, risedronate and zoledronic acid have been linked to a breakdown of the jaw bone (called osteonecrosis of the jaw) following dental work such as dental extractions. Rare cases of atypical fractures of the femoral (thigh) bone have been reported with bisphosphonates. One should notify their physician if they experience pain in the groin or thigh that is present for a few weeks.

Denosumab

Denosumab (Prolia ®) belongs to a class of osteoporosis treatment called a Rank ligand inhibitor.

How Does Denosumab Work?

Denosumab is an anti-resorptive treatment that inhibits the development and activation of osteoclasts (the cells that eat away bone).

How Effective Is It?

Denosumab reduces the risk of fractures of the spine, hip and other sites in women with postmenopausal osteoporosis.

Who Can Take It?

Denosumab can be used to reduce the risk of fractures in postmenopausal women with osteoporosis and to increase bone mass in men with osteoporosis at high risk of fracture. Denosumab can also be used for the treatment and prevention of glucocorticoid-induced osteoporosis in women and men at high risk of fracture.

How Is It Taken?

Denosumab is an injection under the skin given by a trained healthcare professional, twice a year. The dose is 60 mg.

Are There Side Effects?

Side effects may include pain in the muscles, arms, legs or back and a skin condition with itching, redness and/or dryness. It also slightly increases the risk of cellulitis, a skin infection that is treated with antibiotics. Jaw bone problems (ON J) and unusual fractures of the thigh bone may also occur.