Medicines to protect bones

While exercise and nutrition can improve bone health, sometimes, more is needed. There are medicines available to reduce the risk of bone loss and fractures for people at higher risk of low bone density.

Low bone density can lead to conditions called osteopenia and osteoporosis, which can make bones weaker and more fragile.

Your care team may recommend bone-protective medicines if:

• You are taking breast cancer treatments that increase risk of bone loss, such as hormonal therapy
• You have been diagnosed with metastatic breast cancer in the bones

Bisphosphonates, one type of bone-protective medicine, have also been shown to help lower the risk of breast cancer recurrence in postmenopausal women with early-stage breast cancer.

Below, we’ll talk about the different kinds of medicines that can help preserve and protect bones.

Bisphosphonates for bone loss

The most common medicines given to people with low bone density are called bisphosphonates. These medicines slow the cells that break down bones (osteoclasts) to keep them from getting weaker.

Bisphosphonates can be taken as a pill or given by vein (intravenous or IV) .

Bisphosphonate pills

The most common bisphosphonate pills are:

• Alendronate (Fosamax), taken weekly
• Risedronate (Actonel or Atelvia), taken weekly or monthly
• Ibandronate (Boniva), taken monthly

Bisphosphonate pills can have side effects such as heartburn, nausea and upset stomach, or abdominal pain. To reduce the risk of these side effects:

• Take the pill with a full glass (6–8 ounces) of water on an empty stomach.
• Do not take other medications for at least 30 minutes (60 minutes for ibandronate).
• Do not lie, bend down, or eat for 30–60 minutes after you take your pill.
• After the wait time has passed, eat a meal to settle your stomach.

One way to do this:

• Take the pill when you wake up.
• Then, take a morning shower. You will be standing upright through the shower and your morning routine.
• After that, you can eat breakfast.

Bisphosphonates given by intravenous (IV) infusion

Bisphosphonates can also be given by vein as an intravenous (IV) infusion.

The two common intravenous bisphosphonates are both forms of a medicine called zoledronic acid. They are:

• Reclast, given once a year to women who are postmenopausal
• Zometa, given to women with breast cancer that has spread (metastasized) to the bones

Intravenous bisphosphonates may be a good option for people who:

• Have trouble swallowing pills
• Have difficulty with upset stomach that can happen with bisphosphonate pills
• Have trouble remembering to take a pill regularly

Common side effects with intravenous bisphosphonates include flu-like symptoms such as fever, headache, body aches, bone pain, joint pain, and muscle pain. These usually subside a few days after the infusion.

Very rare side effects include eye problems such as pink eye, rare femur fractures, and jawbone cell breakdown (a condition called osteonecrosis of the jaw, or ONJ). You can read more about ONJ below.

Bisphosphonates for reducing risk of recurrence

Bisphosphonates can make it more difficult for breast cancer cells to grow in the bones. For some women at high risk of recurrence, taking bisphosphonates has been shown to reduce the risk of breast cancer recurrence in bones.

A 2015 meta-analysis brought together the findings of 26 previous trials. It found that women who were given bisphosphonates showed a lower risk of recurrence to the bones over 10 years. But the greatest benefits were for women who had been through menopause when treatment began. They showed a lower risk for distant recurrence and death from breast cancer.

The American Society of Clinical Oncologists (ASCO) and the National Comprehensive Cancer Network (NCCN) recommend that postmenopausal women with a high risk of breast cancer recurrence talk with their providers about taking bisphosphonates to reduce risk of recurrence in the bones.

These medicines can help reduce recurrence to the bones whether menopause was natural or caused by breast cancer treatment (early menopause).

The reason bisphosphonates work better in postmenopausal women is not clear. More research is being done to determine the best treatment schedule for bisphosphonates in lowering risk of breast cancer recurrence.

Other medicines for bone health

If bisphosphonates are not working, or your care team thinks a different medicine may work better for you, you may be given one of the treatments below to help manage your bone health:

• Raloxifene (Evista) is a pill taken once a day that can reduce the risk of bone loss by acting like estrogen, which normally signals the bones to rebuild. It may cause hot flashes and, in rare cases, blood clots.
  • Raloxifene is also approved to reduce the risk of a first-time breast cancer in postmenopausal women at high risk due to an inherited genetic mutation, strong family history, or other risk factors.
• Denosumab (Prolia, Xgeva, and biosimilar denosumab-bbdz [Jubbonti]) is part of a class of medicines called RANK ligand inhibitors. Denosumab stops the cells that break down bone tissue and reduces the risk of fracture. It is given by injection once every 6 months.
• Romosozumab (Evenity) is a bone-building medicine known as a monoclonal antibody. It is given in the form of an injection under the skin once a month for 12 months, followed by treatment with a bisphosphonate to maintain the new bone.
• Teriparatide (Forteo) is an injectable treatment for postmenopausal women with very low bone density (osteoporosis). It has shown the ability to regrow some bone density.
• Calcitonin is a medicine made from salmon that helps slow the breakdown of bone in postmenopausal women with osteoporosis. It can be given as a nasal spray or an injection.

Osteonecrosis of the jaw: a rare side effect

Very rarely, bisphosphonates and denosumab can cause a side effect called osteonecrosis of the jaw (ONJ).

• Osteonecrosis of the jaw means that jawbone cells break down and die.
• Gum or other dental disease can increase the risk, so it’s important to talk with your care team about your dental health and see a dentist before starting these treatments.

Early ONJ signs include:

• Jaw pain
• Gums that are red, swollen, or bleeding
• Trouble chewing
• Loose teeth
• Mouth sores
• Numbness or a heavy feeling in the jaw

If ONJ develops further, part of the jaw can become exposed in the mouth. This can cause jaw pain, mouth numbness, and trouble swallowing.

Treatment includes antibiotics, pain medicine, and in some cases, surgery to remove dead jawbone tissue.

It’s important to know that osteonecrosis of the jaw is extremely rare in people taking medicines that protect bones. It is possible to catch ONJ at the first signs and get treatment quickly, without surgery.

Ways to reduce the risk of ONJ:

• Visit your dentist for a cleaning and exam before treatment begins.
• If you smoke, talk with your care team about stopping smoking.
• Let your care team know if you have ever had a facial fracture.
• Let your care team know if you wear dentures.
• Tell your care team if you have any of the early signs of ONJ mentioned above.
• Schedule regular dental check-ups.
• Before any dental work, tell your dentist you are taking a bisphosphonate.
• Let your care team know about dental visits and procedures you have planned.
• Brush your teeth after every meal and before you go to bed. Floss at least once a day, ideally at bedtime.

Hormone replacement therapy and bone health

Hormone replacement therapy (HRT) means taking hormones, including estrogen, to reduce menopausal symptoms such as hot flashes, vaginal dryness, and bone loss.

It’s important to know that hormone replacement therapy that affects the whole body (pills, patches, and some vaginal rings) is not safe for people with a history of breast cancer.

While HRT that affects the whole body is not recommended, researchers have found that low-dose vaginally inserted estrogen (tablets, creams, and some types of vaginal rings) is generally safe for people with a history of breast cancer.

Low-dose vaginal estrogen can reduce symptoms such as vaginal dryness and pain during sex, but it does not protect bones.

More ways to manage bone health

Learn more about bone health and ways to keep your bones strong, including exercise and nutrition:

• Bone health
• Improving bone health