What’s the Best Osteoporosis Medication?

Some bone loss is normal as we age. But osteoporosis can happen when your bones become weaker than expected. At first, it might not cause problems. But as bones become more brittle, osteoporosis can lead to fractures.

Anyone can develop osteoporosis, but it’s more common in women. In fact, it affects 1 in 4 U.S. women age 65 and older. Osteoporosis is a lifelong condition. But you can manage symptoms and reduce bone loss with lifestyle changes and medications. 

Here, we’ll discuss medication options to help strengthen your bones. The best osteoporosis medication for you depends on several factors. Knowing what’s available can help you discuss options with your healthcare team.

What medications treat osteoporosis?

If you have osteoporosis, medications are recommended to lower your risk of fractures. Lifestyle changes can also help. However, they’re most effective if you take medication as well. There are two main types of osteoporosis medications:

• Antiresorptive medications, which prevent bone loss by decreasing bone resorption (the breakdown of old bone)

• Anabolic medications, which help you build new bone 

Typically, antiresorptive medications are the first-choice treatment for osteoporosis. But if you have a very high risk of a fracture, your prescriber might suggest an anabolic medication instead. Your fracture risk is based on several factors. These include your T-score and history of previous fractures.

For most people, the benefits of osteoporosis medications far outweigh the possible risks. Experiencing fractures can be disabling, so it's best to prevent them if possible.

Below, we’ll cover six treatment options and how to choose the best osteoporosis medication for you.

1. Bisphosphonates

Bisphosphonates are antiresorptive medications. They’re first-choice treatment options for osteoporosis. They’re also used in osteopenia, which is a condition of weakened bones that hasn’t progressed to osteoporosis. 

EXPERT PICKS: WHAT TO READ NEXT

• Bisphosphonates versus Prolia: Read about all of the factors that will help you choose between these treatment options.

• Lifestyle changes: If you’re looking for alternatives to medication, check out the lifestyle tweaks that can help you strengthen your bones.

• Exercising with osteoporosis: Exercise is essential to strengthening your bones. Find out the right exercises to help you get the most out of your workout.

Bisphosphonates work by making it harder for certain cells (called osteoclasts) to break down bone.

Medication options

Bisphosphonates are first-choice options for osteoporosis. Oral forms are most commonly used, but there are also intravenous (IV) options. The following bisphosphonates are FDA approved to treat osteoporosis:

• Alendronate (Fosamax), which is taken orally once-daily or once-weekly 

• Risedronate (Actonel), which is taken orally once daily, once weekly, or once or twice monthly

• Ibandronate (Boniva), which can be taken once-monthly as a tablet or every 3 months as an injection

• Zoledronic acid (Reclast), which is given once a year as an IV injection

Alendronate, risedronate, and zoledronic acid can help prevent spine and hip fractures. Ibandronate can prevent spine fractures, but it isn’t known to reduce the risk of hip fractures.

Zoledronic acid is considered a more potent bisphosphonate. It may be a good option if you have trouble taking an oral bisphosphonate. Or it might be a good choice if you prefer a medication that you only need to receive once a year. It’s also a better option than oral bisphosphonates for people at very high risk of fractures.

Risks

The most common bisphosphonate side effects are stomach upset, nausea, and heartburn. You can minimize these problems by staying upright for up to an hour after your dose. The exact amount of time depends on which oral bisphosphonate you’re taking. This can also help minimize your risk of esophageal ulcers. These are a more serious bisphosphonate side effect. Zoledronic acid can also cause injection site reactions or flu-like symptoms. If this does occur, it will be after your infusion.

Another serious (but rare) risk is osteonecrosis of the jaw (ONJ). Atypical fractures and hypocalcemia (low blood calcium) are also rare but serious risks. Bisphosphonates can cause kidney damage as well. To prevent some of these serious risks, your prescriber may recommend a “drug holiday.” This is when you take a long-term break from the medication. If they do recommend this, it will likely be after 3 to 5 years of treatment. 

2. Prolia (denosumab)

Prolia (denosumab) is an antiresorptive monoclonal antibody. It’s a subcutaneous injection, meaning it’s injected under the skin. Prolia is typically considered an alternative to bisphosphonates if they can’t be used. And some guidelines consider Prolia a first-choice option for postmenopausal women at very high risk of fracture. 

One benefit to Prolia is that you only need a dose every 6 months. It works by blocking RANK ligand (RANKL), a protein in the body that’s involved in breaking down bone. Unlike bisphosphonates, however, Prolia doesn’t continue working after you stop treatment. So if you need to stop Prolia, your prescriber will likely recommend another osteoporosis medication.

Risks

One common Prolia side effect is muscle aches and pains. More serious (but rare) risks include hypocalcemia, ONJ, and atypical fractures. It can also cause an increased risk of infections. This is especially true if your immune system is already weakened.

3. Parathyroid hormone analogs

Parathyroid hormone (PTH) analogs are subcutaneous injections. They mimic the effects of natural PTH, a bone-building hormone in the body. There are two PTH analogs available to treat osteoporosis:

• Forteo (teriparatide)

• Tymlos (abaloparatide)

These are anabolic medications. Their bone-strengthening effects are different from antiresorptive medications like bisphosphonates. Anabolic medication effects are greater and occur more quickly. But PTH analogs aren’t first-choice medications in most cases. However, if you have a very high fracture risk, they may be recommended for up to 2 years. Then, Prolia or a bisphosphonate is typically needed to maintain bone strength.

These injections are typically given once daily, and you can administer them yourself.  

Risks

Common Tymlos and Forteo side effects include nausea, dizziness, and aches and pains. More serious risks include high calcium levels (hypercalcemia) and worsening kidney stones.

4. Evenity (romosozumab)

Evenity (romosozumab) is a monoclonal antibody. It’s given as a subcutaneous injection once every month. Evenity is more potent than PTH analogs, so treatment only lasts one year. It’s not typically a first-choice medication for osteoporosis, but it may be used in postmenopausal women at very high risk of fractures.

Evenity has both antiresorptive and anabolic actions. It works by blocking sclerostin, a chemical in the body that typically stops bone growth and promotes bone breakdown.

Risks

Some common Evenity side effects are joint pain, weakness, and nausea.  

Rare risks include stroke or heart attack. Rare long-term Evenity side effects include ONJ and atypical fractures.

5. Selective estrogen receptor modulators (SERMs)

Selective estrogen receptor modulators (SERMs) aren’t first-choice osteoporosis medications for most people. This is because they haven’t been shown to reduce fractures that aren’t in the spine, such as hip fractures. But they may be used for postmenopausal women with osteoporosis if they have a high risk of breast cancer. SERMs may also be used for postmenopausal women who can’t take bisphosphonates or Prolia and have a low risk of blood clots.

Evista (raloxifene) is an SERM that treats osteoporosis in postmenopausal women. It’s a once-daily tablet. Duavee (bazedoxifene / conjugated equine estrogens) is a once-daily tablet. It’s FDA approved for osteoporosis prevention in postmenopausal women. 

SERMs work by activating estrogen receptors (binding sites) in bone. Increased estrogen prevents the breakdown of bone.

Risks

Common Evista side effects include hot flashes and leg cramps. More serious but rare risks include blood clots and strokes.

6. Calcitonin

Calcitonin salmon is an older osteoporosis medication. It’s not commonly used. But it may be an option if it’s been 5 years or more since you started menopause and you aren’t able to use other osteoporosis medications. It comes as a nasal spray or an injection (Miacalcin) that you give yourself once daily.

This medication works by increasing calcitonin levels. Calcitonin is a natural hormone in your body that blocks bone breakdown.

Risks

Common calcitonin nasal spray side effects include nose irritation, joint and back pain, and headache. Common side effects of the injection include nausea, flushing, and injection site reactions.

More serious calcitonin risks can include hypocalcemia and an increased risk of cancer.

Is there a best osteoporosis medication?

There’s no “best” osteoporosis medication for everyone. Your prescriber will consider a few factors when deciding which medication is best for you. These include your fracture risk, medical history, and personal preferences. If you took an osteoporosis medication in the past, they’ll factor that in too. Whether you have insurance can also help determine which medications to consider.

However, there are some general guidelines to help you decide between osteoporosis medications:

• Most people start with an oral bisphosphonate. Your prescriber may also consider IV zoledronic acid if oral bisphosphonates can’t be used. Treatment with bisphosphonates usually lasts at least 3 to 5 years. Then it’s likely your prescriber will recommend a drug holiday. 

• Prolia is a second-choice option if you can’t tolerate bisphosphonates. Or if they aren't a safe option for you. Prolia may also be an option if you have a very high fracture risk. While bisphosphonates come in generic forms, Prolia is brand name only. Prolia’s benefits decline if you stop taking it. This is different from bisphosphonates. So your prescriber will likely suggest taking another osteoporosis medication if you stop Prolia.

• You may need Forteo, Tymplos, or Evenity if you have a very high risk of fracture. After taking these medications for 1 to 2 years, your prescriber may recommend follow-up treatment. This could include a bisphosphonate or Prolia to maintain bone strength.

Some key differences between two medications you may be considering are highlighted below.

Evenity vs. Prolia

Evenity and Prolia are both monoclonal antibodies. But when comparing these medications, Prolia is more commonly used. It’s also FDA approved in men with osteoporosis and for osteoporosis caused by steroids. However, Evenity may be an option if you have a very high fracture risk. This may mean that you have a T-score of less than -3.0 or a history of multiple fractures. 

When considering Evenity versus Prolia, remember that Evenity has a rare risk of heart problems. Prolia doesn’t have that risk. So if you have an existing heart condition, Evenity may not be a good option for you.

Keep in mind that if you need to stop using either of these osteoporosis medications, you’ll likely need to start another one.

Forteo vs. Tymlos

Some research shows that Tymlos might work better than Forteo overall. But experts don’t recommend one over the other for osteoporosis treatment. If your osteoporosis is from taking corticosteroids, Forteo may be preferred since it’s FDA approved for this use.

There’s also a practical difference when comparing Forteo versus Tymlos. Forteo injection pens need to be refrigerated. Tymlos pens can be kept at room temperature for up to 30 days, making them convenient to travel with. 

While Forteo is available as a generic medication, Tymlos is brand name only. 

How to save

There are several ways to save on osteoporosis medications. For example, with a free GoodRx discount, generic Fosamax at certain pharmacies may be as low as $13.77 for a 1-month supply (four tablets).

Prolia and other osteoporosis medications are only available as brand-name medications. But there might still be ways to lower the cost:

• Save with GoodRx: Anyone with a valid prescription, regardless of insurance status, can use GoodRx to purchase a 1-month supply of Duavee at an exclusive cash price of $99.

• Save with patient assistance programs. If you’re uninsured or underinsured, you may be eligible for Prolia’s patient assistance program. The program offers Prolia free of cost if you meet certain income requirements. You may also be able to get Tymlos, Duavee, or Evenity free of cost.

• Save with a copay savings card. If you have commercial insurance, you may qualify for a manufacturer savings card. If you meet the eligibility requirements, Prolia may be as little as $25 per dose. Duavee may be as little as $25. And Forteo may be as low as $4 per month, while Tymlos may be free.

Why trust our experts?

Written by:

Daphne Berryhill, RPh

Daphne Berryhill, RPh, has two decades of experience as a clinical pharmacist. She spent most of her career in the Chicago area practicing in-home infusion.

Edited by:

Amy B. Gragnolati, PharmD, BCPS

Amy Gragnolati, PharmD, BCPS, is a pharmacy editor for GoodRx. Amy currently holds her pharmacist license in Georgia and California.

Reviewed by:

Mandy Armitage, MD

Mandy Armitage, MD, has combined her interests in clinical medicine with her passion for education and content development for many years. She served as medical director for the health technology companies HealthLoop (now Get Well) and Doximity.

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