On April 9, 2019, the U.S. Food and Drug Administration approved a new osteoporosis drug called Evenity. Bones are constantly changed by bone cells called osteoblasts that grow new bone and osteoclasts that remove old bone cells. Evenity is a monoclonal antibody that blocks the effects of the protein sclerostin that encourages the growth of osteoclasts that remove old bone cells. So when you block osteoclasts that remove old bone cells, you increase the size and strength of bones even though you are not increasing the osteoblasts that grow new bone. Evenity has a slightly increased risk for heart attacks and strokes and is very expensive, may not be covered by insurance, and is licensed only for postmenopausal women at high risk for fractures. Another similar drug called Prolia (denosumab) is already on the market.

Your bones are strongest at age 30. After that, you spend the rest of your life losing bone as well as muscle mass. More than 44 percent of adults over age 50 in the U.S. suffer from increased risk for breaking bones when they fall (J Bone Miner Res, 2014 Nov; 29(11): 2520–2526). Up to 25 percent of patients who develop osteoporotic bone fractures suffer another fracture within 10 years, so most doctors treat people who break bones from falling with drugs to slow down their progressive loss of bone (JAMA Netw Open, July, 2018;1(3):e180844). Fewer than 10 percent of women take medications to treat osteoporosis after their first hip fracture (JAMA Netw Open, 2018;1(3):e180826), probably because of the high cost of these drugs and the slightly increased risk for breaking jaw or hip bones in those who take the drugs for more than four years.

Available Drugs to Treat Osteoporosis
• Bisphosphonates include brand names Fosamax, Boniva, Skelid, Reclast, Zometa, Bonefos, Actonel and Aredia, and their generic equivalents. Bones are constantly shedding and making new cells, and after age 30, bones lose more cells than they replace, causing a progressive loss of bones. Bisphosphonate drugs do not build new bone; they slow down the loss of old bone cells. On rare occasions, they have been linked to increased risk for fractures of hip and jaw bones.

• Zoledronic acid or zoledronate is a bisphosphonate given intravenously once a year. It reduces the rate of loss of old bone cells. It has been shown to reduce vertebral fracture risk by 70 percent, hip fractures by 41 percent and other fractures by 25 percent. It should not be given to people with kidney damage.

• Teriparatide (brand name Forteo) is a form of parathyroid hormone given in one-a-day injections. It has been shown to reduce vertebral fracture risk by 65 percent and non-vertebral fractures by 53 percent in treatment lasting 18 months. Side effects include leg cramps, nausea and dizziness, and the drug may be associated with increased bone cancer risk.

• Denosumab (brand name Prolia) is a human monoclonal antibody that over three years has reduced vertebral fracture risk by 68 percent, hip fracture risk by 40 percent and other fractures by 20 percent. It is given as a twice-yearly injection. Side effects include low calcium, skin rashes and infections.

• Romosozumab-aqqg (brand name Evenity) is the new drug recently approved by the FDA. Evenity is a monoclonal antibody similar to Prolia. One dose of Evenity consists of two injections, one immediately following the other, given once a month by a health professional. The injections can be given for only one year as the drug stops working after about 12 doses.

Lifestyle Factors to Make Bones Stronger
Because aging causes everyone to lose bone size and strength, everyone should follow the lifestyle rules for slowing bone loss with aging, whether or not you choose to take bone-strengthening drugs. These include:
• regular weight-bearing exercise
• a healthful anti-inflammatory diet
• not smoking
• restricting alcohol
• getting sufficient dietary calcium and vitamin D
• avoiding drugs that weaken bones
• avoiding obesity and diabetes

My Recommendations
Osteoporosis risk increases with aging in everyone. Drugs may be necessary to prevent fractures for certain people who have osteoporosis, but they can also have side effects. You and your doctor need to discuss these and make your decisions.

The lifestyle habits that help to prevent osteoporosis (listed above) are the same ones that reduce risk for heart attacks, diabetes, dementia, strokes and other life-shortening diseases, so they should be followed by everyone. The recommended lifestyle changes have only positive effects. For more information, see Preventing Osteoporosis

Checked 3/17/22