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

If you are having cancer treatments that are known to increase your risk of osteoporosis your cancer doctor may advise you to take calcium and vitamin D supplements. They will usually organise a fracture risk assessment or a bone density scan (DXA scan) before deciding whether you need to take them.

You can buy vitamin D supplements without a prescription, but always ask your GP what dose to take. If you are thinking about buying calcium supplements, talk to your doctor. You may be able to get enough calcium from your diet.

Bisphosphonates

Bisphosphonates are widely used. They can help to:

  • reduce the risk of fractures in people with osteoporosis
  • prevent bone loss caused by hormonal therapy and other cancer treatments
  • 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 reduce the activity of cells that break down bone (osteoclasts). This slows down bone loss. Bisphosphonates do not replace lost bone but they can stop further bone loss. This helps to make the bone stronger.

Bisphosphonates used to treat osteoporosis

There are several bisphosphonates used to treat osteoporosis. These include:

How to take bisphophonates

Bisphosphonates used to treat bone loss and osteoporosis are usually taken as tablets or capsules. They may be taken daily, weekly or sometimes monthly. A few people may be given bisphosphonates by injection into a vein (intravenously) or as an infusion.

You take the tablets first thing in the morning, on an empty stomach with a glass of water. You need to stay 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 prevent the drug coming back up from the stomach into the gullet, which can happen when lying down or bending.

Side effects of bisphosphonates

Possible side effects include:

  • indigestion
  • a sore throat or inflamed gullet
  • pains in the muscles and joints
  • flu-like symptoms, which usually settle after the first dose.

Rare side effects

  • Thigh bone fractures (atypical fractures)

    A few people taking bisphosphonates have developed fractures of their thigh bone without any obvious cause. Sometimes both thigh bones are affected.

    If you have any thigh, hip or groin pain, tell your doctor and mention 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 loosening of the teeth and problems with the way the gums heal.

    The risk of ONJ is extremely low if you are taking bisphosphonates to treat osteoporosis. Fewer than one person will develop it for every 100,000 patient treatment years. To put it another way, if 10,000 people were treated with bisphosphonate tablets for ten years, one person would get ONJ.

    ONJ is more likely to happen when bisphosphonates are given to treat cancers that have spread to the bones (secondary bone cancer). This is because higher doses of bisphosphonates are used to treat secondary bone cancer.

    Before you start bisphosphonates, talk to your dentist. If you have not been to the dentist for six months or if you have dentures that do not fit well, ask for a check-up. This is because it is important to avoid having a treatment that could affect your jaw bone during bisphosphonate treatment. This includes having a tooth or root removed or dental implants put in. It is fine to have fillings, gum treatments or a scale and polish.

    If you need to have a dental treatment that could affect the jaw while you are taking bisphosphonates, tell your doctor before you have the treatment.

  • Cancer of the gullet (oesophageal cancer)

    Some studies have suggested that taking bisphosphonate as tablets or capsules for five years or more may slightly increase the risk of cancer of the gullet. But other studies have not shown this link. More research is needed before doctors know if there is a link. Because bisphosphonates can cause irritation of the gullet, people taking them are usually checked regularly for gullet problems. Tell your doctor if you have:

    • pain or difficulty when swallowing
    • chest pain
    • new or worsening heartburn.

     

 

Denosumab (Prolia®)

People who have to stop taking bisphosphonates because of problems such as indigestion, a sore throat or inflamed gullet may be given denosumab.

Denosumab is given once every six 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.

Raloxifene (Evista®)

Raloxifene is used to treat osteoporosis in women who have been through the menopause. The drug shares some of the helpful effects of oestrogen, reducing the breakdown of bone and the risk of fractures.

It is only used for women who cannot take bisphosphonates. Women who are taking tamoxifen should not take raloxifene. This is because it may make tamoxifen work less well. Raloxifene is taken daily as a tablet.

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 patches applied to the skin.

Oestrogen replacement

Oestrogen helps protect women’s bones. If your oestrogen levels are reduced as a side effect of your 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 as patches you apply to your skin (transdermal patches).

HRT can have benefits for bone health. But there are also potential side effects or risks from taking HRT. The risks and benefits of HRT are affected by:

  • the type of HRT (combined or oestrogen only)
  • whether HRT is taken as tablets or skin patches
  • your age
  • your general health
  • your family history of blood clots
  • your risk of cancer of the ovary and breast.

The type of cancer you have had can also be an important factor. If you have had breast cancer, HRT may not be suitable for you. Some doctors also think HRT is not suitable for women who have had ovarian cancer or womb cancer. If you have had one of these cancers, your cancer doctor can talk to you about this.

When you are deciding whether to have HRT, it is important to discuss the potential benefits and risks with your doctor. This will help you to decide if HRT is right for you.

Testosterone replacement

If a man has a low testosterone level because of cancer treatment, he can be given testosterone 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 version of PTH called teriparatide (Forsteo®) is made as a treatment in the laboratory. You inject it just under the skin (a subcutaneous injection). A nurse can teach you how to do this. You have it every day for up to 24 months.

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.

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