Best Medicines for Strengthening Bones
Oral bisphosphonates are the first-line pharmacological treatment for strengthening bones due to their proven efficacy, safety profile, and cost-effectiveness compared to other osteoporosis medications. 1
Assessment of Bone Health and Fracture Risk
Before initiating treatment, bone health should be evaluated through:
- Bone mineral density (BMD) testing via DEXA scan
- FRAX calculator to assess overall fracture risk
- Assessment of modifiable risk factors
- Calcium and vitamin D status
Treatment Algorithm Based on Fracture Risk
For Adults ≥40 Years:
Low Fracture Risk (T-score >-2.5 and FRAX 10-year risk <20% for major osteoporotic fracture and <3% for hip fracture):
- Optimize calcium intake (1,000-1,200 mg/day) and vitamin D (600-800 IU/day)
- Lifestyle modifications (weight-bearing exercise, smoking cessation, limiting alcohol)
- No pharmacological therapy needed 2
Moderate Fracture Risk (T-score ≤-2.5 but >-3.5 OR FRAX 10-year risk ≥20% but <30% for major osteoporotic fracture or ≥3% but <4.5% for hip fracture):
High Fracture Risk (Prior osteoporotic fracture OR T-score ≤-3.5 OR FRAX 10-year risk ≥30% for major osteoporotic fracture or ≥4.5% for hip fracture):
- Oral bisphosphonates (first choice)
- Same alternative options as for moderate risk, with stronger recommendation for treatment 2
For Adults <40 Years:
- Low fracture risk: Calcium, vitamin D, and lifestyle modifications
- Moderate-to-high risk: Similar approach as for older adults, starting with oral bisphosphonates 2
Specific Medication Options
First-Line Therapy:
- Oral Bisphosphonates:
- Alendronate: 70 mg orally once weekly
- Risedronate: 35 mg orally once weekly or 150 mg monthly 1
Second-Line Options:
IV Bisphosphonates:
- Zoledronic acid: 5 mg intravenously once yearly 1
Anabolic Agents:
- Teriparatide: Stimulates new bone formation by binding to specific cell-surface receptors, increasing skeletal mass and bone strength 3
RANK-L Inhibitors:
- Denosumab: 60 mg subcutaneously every 6 months; blocks osteoclast differentiation and function 4
Essential Supplements
- Calcium: 1,000-1,200 mg daily (preferably from dietary sources)
- Vitamin D: 600-800 IU daily (serum level ≥20 ng/ml) 2, 1
Calcium citrate may be better absorbed than calcium carbonate, especially in older adults or those taking acid-reducing medications 5.
Lifestyle Modifications
- Regular weight-bearing and resistance training exercise (at least 30 minutes daily)
- Maintaining weight in recommended range
- Smoking cessation
- Limiting alcohol intake to 1-2 drinks per day
- Fall prevention strategies 2, 1
Important Considerations and Caveats
Medication Selection Factors:
- Oral bisphosphonates require proper administration (taken on empty stomach with water, remaining upright for 30-60 minutes)
- Patients with esophageal problems should consider alternatives to oral bisphosphonates
- Renal function must be considered when prescribing bisphosphonates
Monitoring:
- BMD testing every 1-2 years during treatment
- After 5 years of bisphosphonate therapy, reevaluate fracture risk to determine whether to continue or discontinue treatment 1
Safety Concerns:
- Bisphosphonates: Rare risk of osteonecrosis of the jaw and atypical femur fractures
- Denosumab: Risk of hypocalcemia; rebound bone loss if discontinued 4
- Teriparatide: Limited to 2 years of treatment due to safety concerns 3
- Calcium supplements: Potential increased risk of kidney stones and cardiovascular events 6, 7
Special Populations:
- Cancer patients on treatments that affect bone health require special consideration
- Patients on glucocorticoids should receive preventive therapy at lower thresholds 2
The evidence strongly supports that for most patients requiring pharmacological intervention for bone strengthening, oral bisphosphonates provide the best balance of efficacy, safety, and cost-effectiveness 2, 1.