Medications That Can Be Bad for Your Bones

Medications That Can Be Bad for Your Bones

If you take a moment to read the tiny contents of the package insert that comes with your prescription drugs, you will see in the section on side effects that there are many that can harm your bones. Some drugs can cause bone loss and some may increase the chance of breaking a bone. If you have certain diseases, you may not have a choice but to take one of these medications. If you do, it is extra important to take steps to protect your bones.

The most common medications that can harm your bones include:

If you are taking any medications that can harm your bones, these are some general rules to reduce the harm:

  • Know your bone density which can help inform you about your risk of breaking a bone and may be useful to monitor any potential bone loss.
  • If you are at high risk for breaking a bone, your health care provider may suggest an osteoporosis medication to reduce the harmful effects on your skeleton.
  • Take as low a dose as possible, for as short a time as possible – but talk with your healthcare provider before you make any changes.
  • Make sure that you get 3-4 servings of a calcium-rich food every day. If you cannot eat dairy or calcium-fortified food, you may need a calcium supplement.
  • Be sure that you have an optimal vitamin D level (≥ 30 ng/mL or ≥74.9 nmol/L). People with breast cancer and prostate cancer may need higher blood levels of vitamin D.
  • Practice great posture and use good body mechanics to prevent spine fractures.
  • Strengthen your legs and do balance exercises to prevent falls and fractures.
  • Remove trip hazards from your home.

If you are taking high doses of steroid-like pills such as prednisone

Steroids are often used to help reduce inflammation and pain for people who have rheumatoid arthritis, lupus, Crohn’s disease and asthma. Because these diseases are chronic, people often take them for long periods of time. Daily doses of over 5 mg are the most harmful to the bones.

The impact of systemic (oral or IV/IM) steroids on the skeleton happens rapidly, often within three months of starting the drug. Systemic steroids affect the bone remodeling process by decreasing the activity of the bone-building cells (osteoblasts) and increasing the activity of the cells that break down bone (osteoclasts). The combination of these actions causes bone loss quickly.

To lessen the harm to the bones from steroid medications: Stay on as low a dose of the steroid as possible to manage inflammation and pain – try for 5 milligrams or less per day.

Steps your health care provider may take when you start steroid treatment. 

List of common steroid medications that affect the skeleton

  • Prednisone: Deltasone®, Rayos®, Prednisone Intensol®, etc.
  • Prednisolone: Omnipred®, Pediapred®, Pred Mild®, etc.
  • Methyprednisolone: Medrol®, Solu-Medrol®, Depo-Medrol®, ReadySharp®,
    P-Care D40®, P-Care D80®, etc.
  • Dexamethasone: Decadron®, Ozurdex®, DexPak 6 Day®, DexPak 13 Day®, Dexamethasone Intensol®, DexPak 10 day®, Maxidex®, LoCort®, etc.
  • Cortisone: Cortison, Cortisone, Cortisone Acetate, Cortone, Cortistab, Cortisyl, Adreson, etc.
  • Triamcinolone: Aristocort®, Aristocirt Forte®, Aristospan®, Clinacort®, Kenalog-10®, Kenalog-40®, Triamcot®, Triam-Forte®, Triesense®, etc 

If you are taking high doses of thyroid medicines

Patients who take medicine to treat an underactive thyroid need to be cautious that they don’t take too much. Most patients on thyroid medicine have Hashimoto’s thyroiditis and a smaller number take thyroid medicine because of thyroid cancer or Graves disease. Too much thyroid medicine increases the activity of the osteoclasts (the bones that break down bone) and put you at an increased risk for fracture. To find the correct dose, your health care provider will get a thyroid-stimulating hormone (TSH) blood test and once you are on the correct dose, monitor your levels at least once a year.                      

Thyroid hormone requirements decline with age, so a dose that was good for a patient at age 20 or 30, may be too high when they are in their 60s, 70s, 80s or 90s.  Younger patients should target a level of TSH in the lower half of the normal range (especially those diagnosed because of weight gain), while patients in their mid-50s should target a TSH level in the upper half of the normal range. For older patients, studies have shown that a lower TSH level was associated with an increased risk of heart disease.

If you are taking a thyroid medicine, it is important to take thyroid medicine at the same time every day to avoid fluctuations in TSH, and some studies suggest taking it at bedtime works best. Finally, do not take your thyroid medicine with iron or calcium supplements or food because it can affect the absorption of the medicine.  

Steps your health care provider may take when you are taking thyroid medicines. 

List of common thyroid medicines that affect the skeleton

If you are taking drugs that can reduce your estrogen or androgen level

Estrogens and androgens, such as testosterone, are hormones that can worsen some medical conditions such as breast cancer, uterine cancer, prostate cancer, endometriosis and uterine fibroids. The medications used to treat these conditions often reduce the level of estrogen or androgens in your body. This reduction in hormones causes an increase in the activity of the osteoclasts, followed by an increase in bone loss.

Steps your health care provider may take when you start a hormone blocker.

List of common hormone blockers that affect the skeleton

  • Aromatase inhibitors (Arimidex®, anastrozole, Aromasin®, exemestane, Femara®, letrazole, etc.)
  • Androgen/estrogen deprivation therapy/gonadotrophin agonists/antagonists (Lupron®, Lupron Depot®, leuprorelin, Eligard®, leuprolide, Zoladex®, goserelin, Suprefact®, buserelin, Eulexin®, flutaminde, Trelstar®, triptorelin, Vantas®, histrelin, Firmagon®, degarelix, long-term treatment with Cetrotide®, cetrorelix or Antogon®, ganirelix, etc.)
  • Depomedroxyprogesterone acetate injections. (Depo-Provera®, Depo-Ralovera®, etc.) 

If you are taking a drug for diabetes

Some medications used for people with diabetes increase the risk of fractures. TZD drugs cause an increase in the number of fat cells in the bone marrow at the expense of bone-forming osteoblasts. SGLT-2 inhibitors may reduce the bone density at the hip and increase fracture risk, although some data are conflicting. Both type 1 and type 2 diabetes are associated with increased risk of breaking a bone, although bone density is usually lower than average in people with type 1 diabetes and higher than average in people with type 2 diabetes. You should talk with your diabetes doctor before stopping or changing any of your medications.

To lessen the harm to the bones from diabetes medications:

  • If you are at increased risk of breaking a bone, try to avoid the use of a TZD.
  • If you are at increased risk of falls, try to avoid the use of a SGLT-2 inhibitor

Additional steps your health care provider may take when you are taking a drug for diabetes. 

List of common diabetes medications that affect the skeleton

  • Thiazolidinediones or TZDs, (Actos® or pioglitazone, Avandia® or rosiglitazone)
  • SGLT-2 Inhibitors (Invokana® or canagliflozin, Forxiga® or dapagliflozin, Jardiance® or empagliflozin, etc.)

If you are taking an antacid

People who have acid reflux, stress gastritis, or peptic ulcers may take a variety of antacids, both prescription and over the counter, that reduce acid and heartburn or abdominal pain. However, the long-term, daily use of aluminum-containing antacids or proton pump inhibitors (PPI) may affect the absorption of calcium and appears to increase the risk of fracture.

To lessen the harm to the bones from antacids:

  • Consider an H2-blocker such as Zantac® (ranitidine) 75 to 150 mg twice daily instead of a PPI.
  • Consider changes to your diet to reduce acid production.

Additional steps your health care provider may take if you are taking an antacid.

List of common acid-reducing medications that affect the skeleton

  • Antacids with aluminum (Maalox®, Mylanta®, Riopan®)
  • Proton Pump Inhibitors (Prilosec® or omeprazole, Nexium® or esomeprazole, Prevacid® or lansoprazole, Protonix or pantoprozole, Aciphex® or rabeprazole, Dexilent or dexlansoprazole)

If you are taking antidepressants

A common medication for depression is a selective serotonin receptor uptake inhibitor or SSRI. This particular antidepressant medication increases fracture risk and bone loss in older women and is associated with lower bone density in children and men.

To lessen the harm to the bones from antidepressants:

  • Consider a SNRI (serotonin and norepinephrine reuptake inhibitor) instead of an SSRI
  • Avoid SSRIs if you have other factors that increase your risk of breaking a bone

Additional steps your health care provider may take when you start an antidepressant. 

List of common antidepressants that affect the skeleton

  • SSRIs (Prozac®, Paxil®, Zoloft®) 

If you are taking blood thinners and anticoagulants

Patients who are at risk for stroke or blood clots are often prescribed a blood thinner or a medication that reduces the chance of blood clots. These medications prevent the absorption of calcium and affect the bone-building cells leading to bone loss and increased risk of breaking a bone. WarfarinÒ, in particular, may also affect vitamin K metabolism. Newer anticoagulants that don’t inhibit vitamin K such as Pradaxa® (dabigratan), Xarelto® (rivaroxaban), Eliquis® (apixaben) and Arixta appear to be safer for the skeleton than Warfarin or heparin.

Steps your health care provider may take when you are taking blood thinners and anticoagulants. 

List of common blood thinners and anti-coagulants that affect the skeleton

  • Heparin, Lovenox® (low molecular weight heparin), Warfarin® or Jantoven® (coumadin) 

If you are taking loop diuretics

People with high blood pressure, congestive heart disease, kidney disease and liver disease are often prescribed loop diuretics to reduce swelling, water retention or edema. The loop diuretics such as furosemide (LasixÒ) increase the production of urine by the kidneys and removes calcium, potassium and magnesium salts from the body. The loss of calcium in the urine increases bone loss and fracture risk. In contrast, thiazide diuretics cause the kidney to hold on to calcium, and tend to increase bone density. There is also research that connects the use of some loop diuretics with falls and increases the risk of spine fractures.

To lessen the harm to the bones from loop diuretics:

  • Consider changing to a thiazide diuretic.

Additional steps your health care provider may take when you are taking a loop diuretic.

List of common loop diuretics that affect the skeleton

  • Lasix® (furosemide), Edecrin® (ethacrynic acid), Bumex® (bumetanide) and Demadex® (torsemide), Aldactone, Dyazide, Diamox 

If you are taking anti-convulsive medications

Anti-convulsive medications are used for people who have seizures or epilepsy. Some of the medications increase vitamin D metabolism in the liver and lower vitamin D levels. Since vitamin D is necessary for calcium absorption, the use of these medications increases bone loss and fracture risk. 

To lessen the harm to the bones from an anti-convulsive medication:

  • Take enough vitamin D to raise your blood level to 30-50 ng/mL

Additional steps your health care provider may take when you are taking an anti-convulsive medication. 

List of common anti-convulsive medications that affect the skeleton

  • Dilantin
  • Phenobarbital
  • Depakote

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