Several types of medication are used to prevent fractures in people with osteoporosis, or "thinning" bones. They include brand-name and generic drugs, and they all pose a risk of side effects. Some are more effective at preventing certain types of fractures than others.
There's little evidence that medication will help if you have osteopenia, sometimes called "pre-osteoporosis", which is bone density that's lower than normal but not severe enough to be called osteoporosis.
Instead of medication, consider lifestyle changes. That includes making sure that your diet has adequate amounts of calcium and vitamin D, and doing weightbearing exercise, such as walking or lifting weights. Also take precautions to prevent falls in the first place, such as limiting how much alcohol you drink and avoiding sleeping pills if possible. Consider medication only if your bone density worsens to the point where you have osteoporosis-although it's still important to continue the lifestyle changes.
If your doctor diagnoses osteoporosis and recommends medication, we suggest the following Best Buy Drug after taking into account effectiveness, safety, convenience, and cost:
- Generic alendronate
The drug is available as a generic that costs $39 to $63 a month depending on the dose. It has been shown to help prevent fractures of the hip, spine, and other bones in those with osteoporosis. It's usually well-tolerated, but as with all bisphosphonates, the most common side effects include diarrhea, nausea, vomiting, heartburn, esophageal irritation, and bone, joint, or muscle pain. Bisphosphonates can also cause rare but serious side effects that include permanent bone deterioration of the jaw (osteonecrosis) and, when taken for more than five years, a possible increased risk of thigh fracture. So talk with your doctor about how to reduce your risk of side effects.
Most studies of alendronate and the other osteoporosis medications have involved postmenopausal women with osteoporosis, so it's not clear how well they work for men or younger women.
This report was published in September 2013.
- Section 1: Welcome
- Section 2: Who Needs Drugs to Prevent Fractures?
- Section 3: Choosing a Drug to Treat Osteoporosis - Effectiveness and Safety
- Section 4: Our Best Buy Pick
- Section 5: Talking With Your Doctor
- Section 6: How We Picked the Best Buy Drugs for Preventing Fractures
- Section 7: Sharing This Report
- Section 8: About Us
This report on drugs to prevent fractures in people with low bone density, or osteoporosis, is part of a Consumer Reports project to help you find safe, effective medication that gives you the most value for your health care dollar. To learn more about the project and other drugs we've evaluated, go to www.CRBestBuyDrugs.org.
We focus on the medication most often prescribed to treat osteoporosis, a condition in which the inside of bones becomes thin and less dense, weakening them and making them more likely to fracture. There are usually no symptoms of osteoporosis, so people can be unaware that they have the condition until they break a bone. The danger of osteoporosis is that it can lead to fractures of the hip, spine, and wrist, which can be permanently disabling. And fractures have other consequences: One in five women age 50 and older who break a hip will die in less than a year, according to the Agency for Healthcare Research and Quality.
More than 8 million women and 2 million men have osteoporosis, according to our analysis of figures from the National Institute of Arthritis and Musculoskeletal and Skin Disease. Another 30 million men and women are at risk of developing osteoporosis due to low bone mass.
Osteoporosis generally strikes older adults, beginning at around 50, with the highest prevalence seen in men and women over 80. Bones are continually remodeling themselves, shedding old bone and making new bone. After about age 30, bones begin to lose more tissue than they make, so they can become less dense over time. If they become too thin, it's considered osteoporosis. Doctors use a special X-ray, called a bone mineral density test (DXA)-more about it in the next section-to help determine if a patient has osteoporosis.
The 13 medications evaluated in this report are used to prevent thinning bones and fractures due to osteoporosis (see Table 1). They are bisphosphonates- alendronate (Fosamax and generic), ibandronate (Boniva and generic), risedronate (Actonel, Atelvia, and generic), and zoledronic acid (Reclast)-denosumab (Prolia), menopausal hormone therapy (estrogen or estrogen plus other hormones), raloxifene (Evista), and teriparatide (Forteo).
Most studies of these medications have involved postmenopausal women with osteoporosis, so it's not clear how well they work for men or younger women.
All of these drugs except teriparatide work by preventing the destruction of bone. Teriparatide works by stimulating the formation of new bone tissue, but it's approved only for a maximum of two years of treatment.
As Table 1 shows, several of these medications are available as generics; others are available only as relatively expensive brand-name drugs. The monthly retail cost can be $5 to more than $1,500. Certain generic osteoporosis medications might cost as little as $4 for a month's supply through generic-drug programs run by major chain stores, such as Kroger, Sam's Club, Target, and Walmart. For an even better bargain, you might be able to obtain a three-month supply for $10 through those programs. (We note in the price chart starting on the Cost Comparison of Drugs to Prevent Fractures table under the Drug Comparison tab which generic medications are likely to be available through them.) Some stores, such as CVS and Walgreens, require a membership fee to participate, and they might charge higher prices. There might be other restrictions too, so check the details carefully to make sure your drug and dose are covered.
|Table 1. Osteoporosis Medications Evaluated in This Report|
|Generic Name||Brand Name(s)||Available as a generic?|
|Risedronate||Actonel, Actonel with calcium, Atelvia||Yes|
|Selective estrogen receptor modulator|
|Menopausal hormone therapy for women|
|Estradiol/norethindrone||Activella, Femhrt||Yes (Activella)|
|Estradiol/levonorgestrel patch||Climara Pro||No|
|Estradiol patch||Climara, Menostar, Vivelle||Yes (except for Menostar)|
Most of the drugs are available as tablets, but some come in other formulations. Alendronate (Fosamax), for example, is available as a tablet and a liquid; ibandronate (Boniva) comes in tablet form and as an injectable; denosumab (Prolia), teriparatide (Forteo), and zoledronic acid (Reclast) are injectables; and Premarin is available as a tablet, an injectable, and a cream. The so-called "injectables," which require either an injection or intravenous infusion, tend to be more expensive, but they might be options if you are unable to take or tolerate pills.
The medications also vary in how often they are taken (see Cost Comparison of Drugs to Prevent Fractures table). Alendronate tablets come in lower strengths that are taken daily and higher strengths that are taken weekly; ibandronate pills are taken monthly, and the injectable medications range from once a day, to once every three months, to once a year.
That's important, because studies have found that how often you have to take a medication can make a difference in whether you continue to take it. Only about half of the people who start a fractureprevention drug continue with it after a year, but those who take a once-a-week drug are more likely to continue compared with those taking a drug daily. There's not enough evidence to know whether a monthly or less frequent regimen is better than a weekly course.
Side effects are another important consideration. People often stop taking a fracture-prevention drug because of them. The side effects associated with these medications are discussed in more detail beginning on section 3.
The report is based on a comprehensive, expert analysis of the medical evidence available on fractureprevention drugs. There's more information on section 6 and at www.CRBestBuyDrugs.org about how we conducted our evaluation.
This report was published in September 2013.
Who Needs Drugs to Prevent Fractures?
Deciding whether you need a medication should begin with determining your risk of having a bone fracture. You and your doctor should consider factors that increase your risk, such as your age and race, whether you smoke, your alcohol consumption, and family and medical history (see Table 2).
Your doctor will probably arrange for a test called a DXA scan, which uses an X-ray beam to measure bone density at your hips, spine, and possibly your wrists.
But not everyone requires a DXA scan. Consumer Reports medical advisers say that women should have one at age 65, and men at age 70. Postmenopausal women under that age and men 50 and older should be screened only if they:
- Are unusually thin or smoke.
- Have had a fracture from a minor trauma or have a parent who had an osteoporosis-related fracture.
- Have a disease (thyroid or parathyroid disorders, celiac disease, adrenal hyperactivity) or regularly take medication, such as steroids or certain antiseizure drugs, that causes bone loss.
|Table 2. Factors that raise the risk of fracture|
The DXA score is compared with the average score of 30-year-old women. The comparison, called a T-score, is expressed as standard deviations (SD) from that average. The lower the score, the higher the fracture risk. A T-score of minus 2.5 SD or less is considered osteoporosis; a score between minus 1 and minus 2.5 SD is considered osteopenia (or pre-osteoporosis), or bone density that's lower than normal but not severe enough to be called osteoporosis. To make diagnoses more standard, the World Health Organization developed a calculator that uses DXA results plus other risk factors to predict a person's 10-year probability of having a fracture. Known as FRAX, it is expected to shift treatment toward those who really need it. You can determine your risk of having a bone fracture by going to: http://www.shef.ac.uk/FRAX/.
People who learn from the test that they have osteopenia can usually skip taking the medications evaluated in this report. There's little evidence that they help if you have low bone density but not low enough to have osteoporosis. Instead, most people with low bone density are usually better off trying lifestyle changes to help preserve bone mass and prevent the development of osteoporosis (see Table 3). Consider medication only if your bone density worsens.
Lifestyle changes include a diet that contains adequate amounts of calcium and vitamin D, which help form and maintain strong bones. Calcium has been shown to prevent fractures of the hip but not other bones. Some research suggests that calcium supplements might increase the risk of a heart attack, but more studies are needed to determine if that is a real risk. Studies of whether vitamin D reduces fractures have had mixed results depending on the dose and the form of the vitamin used. But the evidence suggests that 700 to 800 I.U. of vitamin D daily, particularly when given with calcium, reduces the risk of hip and non-spine fractures.
Other steps to help prevent osteoporosis include doing weight-bearing exercises, such as walking or lifting weights, which can help strengthen your bones and reduce your chance of falling. And don't smoke, because evidence shows that the habit can worsen bone loss.
Certain medications can also increase bone loss, including corticosteroid medications such as prednisone, the blood thinner heparin, and some drugs for epilepsy-carbamazepine, phenobarbital, phenytoin, primidone, and valproate, according to www.UpToDate.com, a physician website. Talk with your doctor about decreasing your dose or switching to a different medication if you take any of those.
Certain diseases, such as celiac disease, lupus, and rheumatoid arthritis, may worsen bone loss and increase the risk of osteoporosis, according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases. So if you suffer from other conditions, talk with your doctor about whether it increases your chance of developing osteoporosis and ways to reduce your risk.
|Table 3. Lifestyle Changes to Help Prevent Fractures|
|Ensure that your diet contains adequate calcium and vitamin D.||
As noted on section 2, studies of whether vitamin D reduces fractures have had mixed results, but the Institute of Medicine recommends:
|Do weight-bearing exercises.||
|Take precautions to prevent falls.||
Choosing a Drug to Treat Osteoporosis - Effectiveness and Safety
The bisphosphonates, denosumab (Prolia), raloxifene (Evista), and teriparatide (Forteo) can help prevent fractures (see Table 4) in women with osteoporsis. But they pose a risk of side effects (see Table 5) and some are more effective at preventing fractures than others. They also differ in price (see Cost Comparison of Drugs to Prevent Fractures table), ranging from as little as $5 for a month's supply to $1,500 or more a month. Menopausal hormone therapy has not been shown to reduce fractures in women with osteoprosis and it carries a risk of serious side effects.
Most studies have been conducted in postmenopausal women; there is less information about how well the drugs prevent fractures in men or younger women with low bone density.
As you can see in Table 4, all of the bisphosphonates have been shown to reduce the risk of fractures of the hip, spine, and other bones (with the exception of ibandronate; there's no information on whether it prevents other fractures besides those of the spine). But there isn't enough evidence overall to judge whether any of the bisphosphonates are superior than the others in preventing fractures.
The most common side effects associated with bisphosphonates include diarrhea, nausea, vomiting, heartburn, esophageal irritation, and bone, joint, or muscle pain (see Table 5). Those medications can also cause rare but serious side effects that include osteonecrosis, or permanent bone deterioration of the jaw. Studies have found that this occurs in one to 28 people for every 100,000 taking the drug. Some studies have suggested that bisphosphonates increase the risk of esophageal cancer and certain types of thigh fractures when taken for more than five years, but more research is needed to determine whether those risks are due to the medication. Zoledronic acid can cause kidney failure in people with impaired renal function, and some research has found that it might increase the risk of a serious heart problem called atrial fibrillation, but it's not clear if this is due to the medication.
|Table 4. Effectiveness of Drugs to Prevent Fracture in Postmenopausal Women|
|Drug||Reduced risk of spine fractures||Reduced risk of non-spine fractures||Reduced risk of hip fractures|
|Ibandronate||Yes||No information||No information|
|Estrogen* (menopausal hormone therapy)||No||No||No|
* In studies of postmenopausal women with osteoporosis, estrogen did not reduce the risk of fractures. However a large, good quality study that included women whether or not they had osteoporosis showed it reduced the risk of hip and vertebral fractures, but was associated with serious harms.
Menopausal hormone therapy does not reduce the risk of fractures in women diagnosed with osteoporosis. And it actually increases the risk of stroke, heart disease, and breast cancer, so it's generally not used solely to treat or prevent osteoporosis.
Only a few studies have compared bisphosphonates head-to-head with other fracture-prevention drugs, so we can't say whether bisphosphonates are more or less effective than raloxifene or teriparatide in preventing fractures. But those other medications have not been shown to prevent as many different types of fractures as bisphosphonates, and they also cause side effects that rule them out as first options for osteoporosis.
Raloxifene has been shown to reduce the risk of spine fractures, but it's no better than a placebo at preventing other kinds of fractures. Also, it increases the risk of life-threatening blood clots, hot flashes, and muscle pain.
Teriparatide reduces the risk of spine fracture and other non-spine fractures, but there's no evidence that it helps prevent hip fractures specifically. Side effects include headaches, high calcium levels in the blood, and an increased risk of bone cancer when taken at high doses.
Denosumab reduces the risk of spine, hip, and other fractures compared with a placebo, but it hasn't been compared head-to-head with other drugs for fracture prevention. Denosumab is associated with an increased risk of serious infection of the skin, abdomen, urinary tract, and ear; osteonecrosis of the jaw (similar to bisphosphonates); and low calcium levels.
|Table 5. Side Effects of Fracture-Prevention Medication|
|Medication||Side Effects||Special Notes|
Risedronate (Actonel or Atelvia)
Zoledronic acid (Reclast)
|Menopausal Hormone Therapy||
Source: The Agency for Healthcare Research and Quality. Reducing the Risk of Bone Fracture: A Review of the Research for Adults With Low Bone Density.
Our Best Buy Pick
If your doctor diagnoses osteoporosis-not osteopenia or "pre-osteoporosis"-and recommends a medication, we suggest the following Best Buy after taking into account effectiveness, safety, convenience, and cost:
- Generic alendronate
It's available as an inexpensive generic from $39 to $63 a month depending on the dose. It has been shown to help prevent fractures of the hip, spine, and other bones. It's usually well-tolerated, but as with all bisphosphonates, the most common side effects include diarrhea, nausea, vomiting, heartburn, esophageal irritation, and bone, joint, or muscle pain. Bisphosphonates can also cause rare but serious side effects that include permanent bone deterioration of the jaw (osteonecrosis) and when taken for more than five years, a possible increased risk of having a thigh bone fracture. So talk with your doctor about how to reduce your risk of side effects.
If you've taken any bisphosphonate for five years or more, ask your doctor about taking a drug "holiday"-stopping temporarily-to encourage normal bone remodeling and to reduce the risk of side effects. At present, there's no consensus among medical experts about the optimal length of time patients should take a bisphosphonate.
Talking With Your Doctor
It's important for you to know that the information we present here is not meant to substitute for a doctor's judgment. But we hope that it will help you and your doctor arrive at a decision about which osteoporosis medication and dose is best for you, if one is warranted at all, and which will give you the most value for your health care dollar.
1. Mention cost to your doctor.
Bear in mind that many people are reluctant to discuss the cost of medicines with their doctor, and that studies have found that doctors do not routinely take price into account when prescribing medicines. Unless you bring it up, your doctor may assume that cost is not a factor for you.
2. Ask about older medications.
Many people (including physicians) think that newer drugs are better. While that's a natural assumption to make, it's not always true. Studies consistently find that many older medicines are as good as, and in some cases better than, newer medicines. Think of them as "tried and true," particularly when it comes to their safety record. Newer drugs have not yet met the test of time, and unexpected problems can and do crop up once they hit the market. Of course, some newer prescription drugs are indeed more effective and safer. Talk with your doctor about newer vs. older medicines, including generic drugs.
3. Consider generic drugs.
Prescription medicines go "generic" when a company's patents on them have lapsed, usually after about 12 to 15 years. At that point, other companies can make and sell the drugs. Generics are much less expensive than newer brand-name medicines, but they are not lesser quality drugs. Indeed, most generics remain useful medicines even many years after first being marketed. That is why more than 75 percent of all prescriptions in the U.S. today are written for generics.
4. Keep up-to-date records.
Another important issue to talk with your doctor about is keeping a record of the drugs you take. There are several reasons for this:
- First, if you see several doctors, each may not be aware of medicines the others have prescribed.
- Second, since people differ in their response to medications, it's common for doctors today to prescribe several medicines before finding one that works well or best.
- Third, many people take several prescription medications, nonprescription drugs, and dietary supplements at the same time. They can interact in ways that can either reduce the benefit you get from the drug or be dangerous.
- Fourth, the names of prescription drugs-both generic and brand-are often hard to pronounce and remember.
For all these reasons, it's important to keep a written list of all the drugs and supplements you take and periodically review it with your doctors.
5. Know the facts.
Finally, always be sure that you understand the dose of the medicine being prescribed and how many pills you are expected to take each day. Your doctor should tell you this information. When you fill a prescription at a pharmacy, or if you get it by mail, check to see that the dose and the number of pills per day on the bottle match the amounts your doctor told you.
How We Picked the Best Buy Drugs for Preventing Fractures
Our evaluation is primarily based on an independent scientific review of the evidence on the effectiveness, safety, and adverse effects of drugs for preventing fractures. A team of physicians and researchers at the Agency for Healthcare Research and Quality conducted the analysis as part of the Comparative Effectiveness Program.
A synopsis of AHRQ's analysis of fracture-prevention drugs that was written by Oregon Health & Science University's Drug Effectiveness Review Project, or DERP, forms the basis for this report. A consultant to Consumer Reports Best Buy Drugs is also a member of the Oregon-based research team, which has no financial interest in any pharmaceutical company or product.
The full AHRQ review of fracture-prevention drugs is available at http://effectivehealthcare.ahrq.gov/ehc/products/160/1007/CER53_LowBoneDensity_FinalReport_20120823.pdf. (It's a long and technical document written for physicians.)
The drug costs we cite were obtained from a health care information company that tracks the sales of prescription drugs in the U.S. Prices for a drug can vary quite widely, even within a single city or town.
The prices in this report are national averages based on sales of prescription drugs in retail outlets. They reflect the "cash" or retail price paid for a month's supply of each drug in May 2013. As noted in the Cost Comparison of Drugs to Prevent Fractures table, some of the osteoporosis medications are available through discount generic-drug programs run by chain stores. But these programs can change which medications are covered, so those prices are not used when selecting the Best Buy picks.
Consumer Reports Best Buy Drugs selected the Best Buy picks using the following criteria. The drug (and dose) had to:
- Be approved by the FDA for treating osteoporosis.
- Have a safety record equal to or better than other osteoporosis medications.
- Have an average price for a 30-day supply that was substantially lower than the most costly fractureprevention drug meeting the first two criteria.
The Consumer Reports Best Buy Drugs methodology is described in more detail in the methods section at www.CRBestBuyDrugs.org.
Sharing This Report
This copyrighted report can be downloaded free, reprinted, and disseminated for individual noncommercial use without permission from Consumers Union or Consumer Reports® magazine as long as it is clearly attributed to Consumer Reports Best Buy Drugs™. We encourage its wide dissemination as well for the purpose of informing consumers. But Consumers Union does not authorize the use of its name or materials for commercial, marketing, or promotional purposes. Any organization interested in broader distribution of this report should e-mail email@example.com. Consumer Reports Best Buy Drugs™ is a trademarked property of Consumers Union. All quotes from the material should cite Consumer Reports Best Buy Drugs™ as the source.
2013 Consumers Union of U.S. Inc.
Consumer Reports is an independent and nonprofit organization whose mission since 1936 has been to provide consumers with unbiased information on goods and services and to create a fair marketplace. Its website is www.ConsumerReports.org.
Consumer Reports Best Buy Drugs is a publiceducation project administered by Consumers Union. These materials were made possible by the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by a multistate settlement of consumer-fraud claims regarding the marketing of the prescription drug Neurontin.
The Engelberg Foundation provided a major grant to fund the creation of the project from 2004 to 2007. Additional initial funding came from the National Library of Medicine, part of the National Institutes of Health. A more detailed explanation of the project is available at www.CRBestBuyDrugs.org.
We followed a rigorous editorial process to ensure that the information in this report and on the Consumer Reports Best Buy Drugs website is accurate and describes generally accepted clinical practices. If we find an error or are alerted to one, we will correct it as quickly as possible. But Consumer Reports and its authors, editors, publishers, licensers, and suppliers cannot be responsible for medical errors or omissions, or any consequences from the use of the information on this site. Please refer to our user agreement at www.CRBestBuyDrugs.org for further information.
Consumer Reports Best Buy Drugs should not be viewed as a substitute for a consultation with a medical or health professional. This report and the information on www.CRBestBuyDrugs.org are provided to enhance your communication with your doctor rather than to replace it.
Cost Comparison of Drugs to Prevent Fractures
Note: If the price box contains a , that indicates the dose of that drug is likely available for a low monthly cost through discount programs offered by large chain stores. For example, Kroger, Sam's Club, Target, and Walmart offer a month's supply of selected generic drugs for $4 or a three-month supply for $10. Other chain stores, such as Costco, CVS, Kmart, and Walgreens, offer similar programs. Some programs have restrictions or membership fees, so check the details carefully for restrictions and to make sure your drug is covered.
Narrow your list
|Generic Name||Brand Name(s)A||Generic?||Formulation and Frequency of DoseB||Average Cost for a Month's SupplyC|
|1||Alendronate 5 mg tablet||Generic||Yes||One pill daily||$63|
|1||Alendronate 10 mg tablet||Generic||Yes||One pill daily||$61|
|1||Alendronate 35 mg tablet||Generic||Yes||One pill weekly||$39|
|1||Alendronate 70 mg tablet||Generic||Yes||One pill weekly||$41|
|Alendronate 70 mg tablet||Fosamax||No||One pill weekly||$132|
|Ibandronate 150 mg tablet||Generic||Yes||One pill monthly||$130|
|Ibandronate 150 mg tablet||Boniva||No||One pill monthly||$183|
|Ibandronate 3 mg/3 mL injectable||Boniva||No||3 mg IV every three months||$200|
|Risedronate 5 mg tablet||Actonel||No||One pill daily||$163|
|Risedronate 35 mg tablet||Actonel||No||One pill weekly||$181|
|Risedronate 150 mg tablet||Actonel||No||One pill monthly||$189|
|Risedronate 35 mg delayed-release tablet||Atelvia||No||One pill weekly||$174|
|Zoledronic acid 5 mg/100 mL injectable||Reclast||No||5 mg infusion once a year||$107|
|Zoledronic acid 5 mg/100 mL injectable||Generic||Yes||5 mg infusion once a year||$47|
|Selective estrogen receptor modulator|
|Raloxifene 60 mg tablet||Evista||No||One pill daily||$213|
|Teriparatide 600 mcg/2.4 mL unit||Forteo||No||20 mcg injection once daily||$1,573|
|Denosumab 60 mg/mL injection||Prolia||No||60 mg/mL injection every six months||$220|
- "Generic" means this is a generic drug, as noted in column three as well.
- As commonly recommended or prescribed.
- Prices reflect nationwide retail average in May 2013, rounded to the nearest dollar. Information derived by Consumer Reports Best Buy Drugs from data provided by Symphony Health Solutions, which is not involved in our analysis or recommendations.