Drug treatments to protect your bones
About drug treatments for bone health
Your doctor may suggest you have treatment to protect your bone health. This may be because:
- bone health tests show you have low bone density or a high risk of fracture
- you are having a cancer treatment that puts you at a high risk of changes in your bone health.
Calcium and vitamin D supplements
you are having a cancer treatment that puts you at a high risk of changes in your bone health.
- are not getting enough calcium or vitamin D
- are having a treatment that can increase your risk of osteoporosis.
They may do blood tests to check your calcium levels. Or they may organise a fracture risk assessment or DXA scan before deciding whether you need to take supplements.
If you need supplements, your doctor may prescribe them for you. Or you can buy vitamin D supplements without a prescription.
If you are thinking about buying calcium supplements, always talk to your specialist doctor or GP. They can talk to you about whether you need to take them and what dose you should take. You may be able to get enough calcium from your diet.
Your doctor may measure your blood calcium levels regularly if you are having bisphosphonate treatment. If you are having bisphosphonate treatment, you may also be prescribed calcium and vitamin D supplements to take as part of the treatment.
Bisphosphonates
Bisphosphonates are widely used. They can help to:
- prevent bone loss caused by hormone therapy and other cancer treatments
- reduce the risk of fractures in people with osteoporosis
- prevent cancer spreading to the bone
- prevent cancer spreading to the bone
- treat cancer that has spread to the bone (secondary bone cancer or bone metastases).
How do bisphosphonates work?
Bisphosphonates used to treat osteoporosis
There are several bisphosphonates used to treat osteoporosis. These include:
- alendronic acid (Fosamax®)
- ibandronic acid (Bonviva®)
- risedronate sodium (Actonel®)
- zoledronic acid (Aclasta®).
How to take bisphophonates
Bisphosphonates used to prevent bone loss and treat osteoporosis are usually taken as tablets or capsules. You may take them daily, weekly or sometimes monthly.
You take the tablets first thing in the morning on an empty stomach. Take them with a glass of water. You need to sit or stand upright for 30 to 60 minutes after taking the tablet. This helps the drug move quickly into the stomach and reduces the risk of it staying in the throat or gullet, where it can cause irritation. It also helps stop the drug coming back up from the stomach into the gullet. This can happen when you are lying down or bending.
Some people with osteoporosis may be given bisphosphonates by a drip (infusion) into a vein (intravenously). It can usually be given in the outpatient department at the hospital.
Side effects of bisphosphonates
Possible side effects of bisphosphonates include:
- indigestion
- a sore throat or inflamed gullet (the tube that goes from the mouth to the stomach)
- pains in your muscles and joints
- flu-like symptoms, which usually settle after the first dose.
Talk to your cancer doctor or GP if you have any of these side effects.
If swallowing is painful or difficult, or if you have indigestion that is new or getting worse, tell your doctor before taking any more of this drug.
Rare side effects
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Thigh bone fractures (atypical fractures)
A small number of people taking bisphosphonates have developed fractures in their thigh bone without any obvious cause. Sometimes both thigh bones are affected.
If you have any pain in your thigh, hip or groin, tell your doctor and explain that you are taking bisphosphonates. They can arrange tests to check the thigh bones for any signs of weakness or fracture. -
Osteonecrosis of the jaw (ONJ)
A rare side effect of bisphosphonate treatment is osteonecrosis of the jaw (ONJ). It happens when healthy bone tissue in the jaw becomes damaged and dies. This can cause loose teeth and problems with the way the gums heal. The risk of ONJ is very low if you are taking bisphosphonates to treat osteoporosis. If 10,000 people were treated with bisphosphonate tablets for 10 years, 1 person would get ONJ.
ONJ is more likely to happen when bisphosphonates are given to treat cancer that has spread to the bones (secondary bone cancer). This is because higher doses of bisphosphonates are used to treat secondary bone cancer.
Your doctor will advise you to see your dentist before you start bisphosphonate treatment. If you have not been to the dentist for 6 months, or if you have dentures that do not fit well, ask for a check-up.
It is important to avoid having dental treatment that could affect your jawbone during bisphosphonate treatment. This includes having dental implants put in or having a tooth or root removed, except in an emergency. But it is fine to have fillings, gum treatments or a scale and polish.
If you need dental treatment that could affect the jaw while you are taking bisphosphonates, tell your doctor before you have the dental treatment.
Denosumab (Prolia®)
Your doctor may give you denosumab if you have to stop taking bisphosphonates because of problems such as indigestion, a sore throat or an inflamed gullet.
You have denosumab once every 6 months as an injection just under the skin (a subcutaneous injection). If you have denosumab, your doctor may advise you to take calcium and vitamin D supplements.
Denosumab can cause some side effects. These include:
- skin, urine and chest infections
- constipation
- pain in the arms or legs
- a rash.
Rarely, denosumab can also cause osteonecrosis of the jaw (ONJ) or atypical thigh bone fractures.
More information about this treatment
This information is correct at time of publishing. But sometimes the types of cancer this treatment is used for, or treatment side effects, may change between revision dates.
You can talk to your cancer team if you want more detailed information about this treatment. Or visit the electronic Medicines Compendium (eMC) website, which has patient information leaflets (PIL) for individual drugs.
Raloxifene (Evista®)
Raloxifene is used to treat osteoporosis in women who have been through the menopause. It is only used for women who cannot take bisphosphonates. You take raloxifene daily as a tablet.
The drug has some of the helpful effects of oestrogen. It can reduce the breakdown of bone and the risk of fractures.
But women who are taking tamoxifen should not take raloxifene. This is because raloxifene can make tamoxifen less effective.
Hormone replacement therapy (HRT)
There are different types of hormone replacement therapy for both men and women. They can be given as tablets, injections, gels or skin patches.
Oestrogen replacement
Oestrogen helps protect women’s bones. If your oestrogen levels are low because of cancer treatment, your doctor may give you HRT to replace the oestrogen. This can help to protect bone health and reduce menopausal symptoms.
HRT may contain oestrogen and progesterone. This is called combined HRT. Or it may contain oestrogen only. It is most commonly given as tablets or skin patches (transdermal patches).
HRT can have benefits for bone health. But there are also possible side effects or risks from taking HRT. The risks and benefits of HRT depend on:
- the type of HRT (combined or oestrogen only)
- whether HRT is taken as tablets or skin patches
- your age
- your general health
- whether you have a family history of blood clots
- the type of cancer you have had
- your risk of cancer of the ovary and breast.
HRT is not suitable for everyone. Your doctor will tell you if it is suitable for you. If you are thinking about having HRT, it is important to discuss the possible benefits and risks with your doctor. This will help you decide if HRT is right for you.
Testosterone replacement
If you have a low level of testosterone because of cancer treatment, you can have testosterone replacement to get back to a normal level. This helps increase bone density.
If you have had prostate cancer, testosterone therapy may not be suitable for you. Your cancer doctor can talk to you about this.
Treatment with parathyroid hormone (PTH)
The parathyroid glands make parathyroid hormone (PTH). These glands are attached to the thyroid gland in the front of the neck. PTH helps the body absorb calcium and stimulates the body to make bone.
A type of PTH called teriparatide (Forsteo®) is made as a treatment in a laboratory. You inject it just under the skin (a subcutaneous injection). A nurse can teach you how to do this yourself. You have the injection every day for up to 24 months (2 years).
People who have broken bones because of severe osteoporosis may be given teriparatide. It cannot be given to people with cancer in the bone. It is also not suitable for people who have had radiotherapy to an area of bone.
About our information
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References
Below is a sample of the sources used in our bone health information. If you would like more information about the sources we use, please contact us at cancerinformationteam@macmillan.org.uk
National Institute for Health and Care Excellence (NICE). Bisphosphonates for treating osteoporosis. TA464. 2019 www.nice.org.uk/guidance/ta464 (accessed Sept 2019).
National Institute for Health and Care Excellence (NICE). Osteoporosis: assessing the risk of fragility fracture. CG146. 2017. www.nice.org.uk/guidance/cg146 (accessed Sept 2019).
National Institute for Health and Care Excellence (NICE). Osteoporosis: Quality standard QS149. 2017. www.nice.org.uk/guidance/qs149 (accessed Sept 2019).
Royal Osteoporosis Society (ROS). Care: Frameworks and guidance. 2019. theros.org.uk/healthcare-professionals/courses-and-cpd/osteoporosis-resources-for-primary-care/frameworks-and-guidance (accessed Sept 2019).
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Reviewers
This information has been written, revised and edited by Macmillan Cancer Support’s Cancer Information Development team. It has been reviewed by expert medical and health professionals and people living with cancer. It has been approved by Chief Medical Editor, Professor Tim Iveson, Consultant Medical Oncologist.
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