Osteoporosis Drugs That Build and Restore Bone: Are These Right for You?

For decades, the first-line treatment for osteoporosis was a type of medication called antiresorptive agents, which work by slowing down the rate of bone loss. Now, though, there’s a newer treatment available: anabolic agents, which work a little differently in the body.

Anabolic agents “go a step further by stimulating new bone formation, which can make bones stronger and reduce the risk of fractures,” says Rachel Fishman Oiknine, MD, a board-certified endocrinologist affiliated with MDVIP, in St. Louis.

Here’s a closer look at how they work, and who might be a candidate.

Anabolic agents work by stimulating certain cells in the bone called osteoblasts to rapidly make new bone. “It’s much like when we were younger and still growing our skeletons,” says Susan Bukata, MD, the chair of the department of orthopedic surgery at the University of California in San Diego.

“Some of this new bone actually reconnects parts [of the bone] that have separated from each other,” she continues, “sort of like filling in a pothole or connecting two parts of a walkway back together after a part has broken away. Anabolic drugs make the bone stronger not only with new bone formation, but also with these bone repairs.”

• abaloparatide (Tymlos) Abaloparatide is a type of medication that mimics the parathyroid hormone, which is involved in bone health. The drug stimulates the parathyroid hormone receptors in these bones and cartilage, which helps promote the growth of new bone cells. Abaloparatide was approved in 2017 and is given as a subcutaneous injection once a day, usually in the stomach.
• teriparatide (Forteo) Teriparatide is also a type of medication that mimics the parathyroid hormone. Like abaloparatide, it stimulates parathyroid hormone receptors in the bones and cartilage to promote the growth of new bone cells. Teriparatide was approved for osteoporosis in 2002, and is given as a subcutaneous injection once a day, usually in the stomach.
• romosozumab (Evenity) Romosozumab, a monoclonal antibody, was approved for osteoporosis in 2019. The medication works by binding to and inhibiting sclerostin, which results in an increase in bone; the medication also acts as an antiresorptive agent, helping to slow down the rate of bone loss. Romosozumab is administered as a monthly injection at a healthcare provider's office.

Anabolic therapies for osteoporosis can be effective, but right now, they aren’t a first-line treatment for everyone. “These drugs are offered to patients who have a high or very high risk of fracture,” says Dr. Bukata. This includes:

• People who’ve already had at least one fracture
• People who have low bone density (that is, they have a T-score of -2.8 or lower on a bone mineral density test)
• People who continue to experience bone loss despite taking other bone-strengthening medications (for example, those who need to take steroids over the long term)

Anabolic medications are considered safe, but as with any drug, there is always a risk of side effects. For certain people, they may also be contraindicated. In particular, says Dr. Fishman Oiknine, “these medications may not be recommended for people with certain bone diseases, a history of radiation to the skeleton, or bone cancer.”

Romosozumab may increase the risk of heart problems among those with cardiovascular issues, and should not be used by people who’ve had a heart attack or stroke within the previous year. If you are having dental work, there is an increased chance of having a severe problem with your jaw.

“It’s important to discuss your medical history [with your doctor] before starting treatment,” says Fishman Oiknine.

• Nausea
• Hypercalcemia (high calcium levels in the blood)
• Hypercalciuria (high calcium levels in the urine)
• Headache
• Dizziness
• Injection site reactions
• Joint and bone pain
• Muscle spasms
• Swelling in the ankles, hands, or feet

Before you start taking an anabolic agent for osteoporosis, you’ll need to have a discussion with your doctor about whether they’re right for you. Fishman Oiknine suggests the following:

• Am I at high risk of a fracture based on my bone density levels or other risk factors?
• Which medication for osteoporosis do you recommend taking and why?
• What type of monitoring, if any, will I need during treatment?
• Will I need regular bone density tests and blood work, and how often?
• Will my insurance cover these medications?
• Can I take any supplements, such as calcium or vitamin D, while I’m taking medication?
• How long will I need to take the medication, and what (if anything) will I take next?
• Are there any nonpharmaceutical treatments I should take?

• Anabolic agents are a newer type of treatment for osteoporosis; they work by stimulating the growth of new bone.
• There are three anabolic agents approved to treat osteoporosis. Currently, they’re given to treat people who have a high risk of fracture.
• Anabolic agents are considered safe, but they still carry the risk of serious side effects. Talk to your doctor about which option may be the best fit for you.