Alendronate (brand name Fosamax) belongs to the category of drugs known as bisphosphonates, which work by blocking or slowing the breakdown of bone. Your body incorporates bisphosphonates into the bone surface by binding it to the cells where active destruction of bone takes place. The drugs themselves do not stop bone breakdown, but that placement serves to slow down the whole process by limiting the locations where breakdown can occur. That in turn allows a better balance between formation of new bone and destruction of old to be established. Bone density loss will stop, and bone can be built back up. This is why proper diet, exercise, and supplements are so important in combination with medication. When you’re doing all you can to alter how bone is built, you also need to provide the best fuel to maximize effectiveness. Drugs alone will never provide optimal results. As we’ve seen, good cement (or good bones) requires a balance of high-quality materials.
Alendronate is used for both prevention of bone density loss and treatment of osteoporosis. For anyone who can’t—or doesn’t want to—use hormone replacement therapy, it can be the best pharmacological option. Like all bisphosphonates, it works by inhibiting bone breakdown, so bone density increases (or at the very least stops decreasing). The rate of fractures is reduced, and so are deformities in the spine and loss of height.
Eighty-six percent of patients using alendronate preventively, and 96 percent using it to treat osteoporosis, have increases in bone density. You can expect 6 percent increases the first year, with 2 percent gains per year after that. Studies show reductions in all types of fractures of about 50 percent independent of the specific bone density results. That is, even if your bone density doesn’t increase, or doesn’t increase much, on alendronate, you will still gain significant protection from fractures. And that is, after all, the main goal of any therapy for low bone density. The drug also results in fewer spine deformities and significantly lessened height loss. Alendronate also reduces disability and lessened activity due to vertebral fractures, and reduces the hospitalization rate for osteoporosis-related injuries—and staying out of the hospital is one of the key goals in managing osteoporosis. Better still, of course, is to preserve your bone density in the first place, which alendronate can help you do.
Alendronate is nonhormonal, so it is good for women who do not use hormone replacement therapy. It provides bone benefits equivalent to those of estrogen. It does not protect the heart the way estrogen does, but it also does not increase cancer risks. The combination of estrogen and alendronate is even better than either one alone.
Alendronate is generally the first choice of drug therapy for men, since men don’t have the same hormonal issues as women do. It is FDA approved for treatment of bone loss caused by steroids, which is also a separate problem from the usual hormonal issues men or women face.
Pregnant women should not take alendronate. And unless your bone scan shows your density to be at least two standard deviations below peak (in the lowest 20 to 30 percent for people your age) you should give diet, exercise, and supplements a serious try before considering drug treatment. However, if your N-telopeptide level is high—indicating a high fracture risk and rapid progression—you may need the additional protection of drugs regardless of your bone density.
The most common—though still unlikely—side effect of alendronate is stomach acid reflux. Others are nausea, indigestion, abdominal pain, constipation, and diarrhea. The risk of stomach problems increases when used with NSAIDs like aspirin, which can cause similar symptoms, and increases as you get older. The most serious—though uncommon—side effect is irritation and inflammation of the esophagus, leading, in the most extreme cases, to ulcers in the esophagus. A reformulated coating on Fosamax capsules has greatly reduced the incidence of this side effect by moving the medicine through the esophagus more quickly.
If you do have a problem with reflux, careful dosing may help. Just 5 mg daily is the usual dose for prevention, and 10 mg a day is for treatment of established osteoporosis. The lower the dose, the less likely you are to experience side effects. Take alendronate with a large cup of water first thing in the morning, and wait at least half an hour before having anything else to eat or drink or taking any other medication. That allows it to be well absorbed and helps limit any effects on your digestive tract. Staying upright for that half hour also helps. Ask your doctor to start you off by slowly increasing your dose to the level right for you, to give your body a chance to adjust to the drug and, again, limit side effects. Don’t be tempted to divide tablets, as that may increase irritation.
New studies have shown the effectiveness of “pulsing” alendronate—taking larger doses less often. Your doctor might recommend, for example, seven pills once a week, rather than one every day. For people who do experience side effects, having them only once a week, rather than every day, may make using the drug much more agreeable.
The very long-term effects of alendronate are still unclear, though experts are satisfied with the safety and effectiveness overall. Beneficial results may last after you stop taking it, but generally it is a prescription you should stay on as long as your bones are benefiting. As with any drug therapy, your doctor should monitor your progress closely.
A new bisphosphonate released after the first publication of this book is risedronate. Actually an older medication reformatted for osteoporosis, risedronate is at least as effective—if not more so—than alendronate (Fosamax), and is more user-friendly. Packaged with a new coating that makes it move through the esophagus more quickly, avoiding the reflux problems some patients experience with alendronate. It is also given in much smaller doses. I’m not changing anything for my patients currently using alendronate with no side effects, but in new cases I now prefer risedronate.
The first form of bisphosphonate used for prevention of osteoporosis, etidronate, is no longer commonly used. Originally, it was developed for a bone disease and for bone cancer, and for many years was the only recourse against osteoporosis. But while etidronate does prevent bone loss by slowing breakdown of old bone, the preserved bone was increasingly made of old or damaged cells. And etidronate also interferes with formation of new bone. On this drug, your bones will be denser, but also perhaps more brittle, exposing you to a higher fracture risk. The long-term effects of taking the drug remain unknown, and studies show that the benefits may wear off after about two years.
Etidronate remains a relatively inexpensive drug and has few side effects. But because of the threat of its creating osteomalacia (soft bones) over the long term, it is rarely used now that more effective options are available. If it is used, it should be taken cyclically (two weeks on, twelve weeks off) to minimize the problems with new bone formation. And it should always be used in conjunction with calcium supplements. But I’d recommend you steer clear of it altogether.
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