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Take a moment to read the small print on the package insert that comes with your prescription medicines. You will see in the section on side effects that some can harm your bones. Some medicines can cause bone loss, some may increase your risk of a fall, 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 medicines. If you do take certain medicines that can cause bone loss or increase your risk of breaking a bone, it is very important to take steps to protect your bones.
Here are some general rules to reduce the harm to your bones from medicines that can cause bone loss and otherwise harm your bones:
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.
Triamcinolone: Aristocort®, Aristocirt Forte®, Aristospan®, Clinacort®, Kenalog-10®, Kenalog-40®, Triamcot®, Triam-Forte®, Triesense®, etc.
Inhaled steroids
Recently published research suggests that very high doses of inhaled steroids also can be bad for the bones. These medicines are used to relieve allergy symptoms, treat asthma symptoms, and prevent asthma attacks. If used as prescribed, these medicines should not cause harm to the bones. If they are used regularly, at higher doses, and for longer periods of time, they might affect the bones.
Very high doses are > 400 mcg/day budenoside or beclomethasone, or > 200 mcg/day fluticasone.
Common inhaled steroids
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. A smaller number take thyroid medicine because of thyroid cancer or Graves’ disease. Too much thyroid medicine increases the activity of the osteoclasts (the bone cells that break down bone) and put you at a higher risk of fracture. To find the correct dose, your health care provider will give you a thyroid-stimulating hormone (TSH) blood test. Once you are on the correct dose, your health care provider will monitor your levels at least once a year.
Thyroid hormone requirements decline with age. A dose that was good for a patient at age 20 or 30 may be too high for someone 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). 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 it at the same time every day to avoid fluctuations in TSH. Some studies suggest taking thyroid medicine at bedtime works best. Finally, do not take your thyroid medicine with iron or calcium supplements or food, which can affect the absorption of the medicine.
Dessicated thyroid gland: Armour® Thyroid
Estrogens and androgens (like testosterone) are sex hormones that can fuel some medical conditions such as breast cancer, uterine cancer, prostate cancer, endometriosis and uterine fibroids. The medicines used to treat these conditions often reduce the level of estrogens 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.
Some medicines that treat people with diabetes increase the risk of fractures. TZD medicines 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 bone density at the hip and increase fracture risk, although data are conflicting. Both type 1 and type 2 diabetes are associated with increased risk of breaking a bone. Bone density is usually lower than average in people with type 1 diabetes but higher than average in people with type 2 diabetes. You should talk with your diabetes doctor about how your medicines can affect your bones.
Common diabetes medications that affect the skeleton
Certain stomach medicines, such as PPIs or antacids containing aluminum
People who have acid reflux, stress gastritis, or peptic ulcers may take a variety of antacids, both prescription and over the counter, to reduce acid and heartburn or abdominal pain. However, the long-term, daily use of aluminum-containing antacids or proton pump inhibitors (PPI) may affect how your body absorbs calcium. These medicines also appear to increase the risk of fractures.
To lessen the harm to the bones from antacids:
Selective serotonin receptor uptake inhibitors, or SSRIs, are a common type of medicine taken for depression or anxiety. SSRIs increase fracture risk and bone loss in older women and are associated with lower bone density in children and men.
To lessen the harm to the bones from antidepressants:
Lithium is used widely to treat bipolar disorder. Mood stabilizer medicines containing lithium can increase parathyroid activity. This can cause bone to be absorbed more quickly than new bone is created.
Patients who are at risk for stroke or blood clots are often prescribed a blood thinner or a medicine that reduces the chance of blood clots. These medicines also prevent your body from absorbing calcium and affect the cells that build bone, leading to bone loss and increased risk of breaking a bone. Warfarin, 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.
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. Loop diuretics like furosemide (Lasix®) increase production of urine by the kidneys and remove 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, which tends to increase bone density. There is also research that connects the use of some loop diuretics with falls and increased risk of spine fractures.
To lessen the harm to the bones from loop diuretics:
Anticonvulsant medicines are used for people who have seizures or epilepsy. Some of these medicines increase vitamin D metabolism in the liver and lower vitamin D levels. Since vitamin D is necessary for calcium absorption, the use of these medicines increases bone loss and fracture risk.
To lessen the harm to the bones from an anti-convulsive medication:
Use of certain HIV medicines has been linked to bone loss. Studies have shown using HIV medicines can cause bone loss of 2-6% in the first two years after starting treatment. That is about the same amount of bone loss seen in women after the onset of menopause. Researchers are still determining which HIV medicines affect the bones, and which don’t.
To lessen the harm to the bones from antiretroviral therapies:
Tramadol is a synthetic opioid medicine commonly used to treat pain. Studies have found that use of tramadol is associated with greater risk of hip fracture than other types of pain relievers.
Originally posted: 11/12/19 – Revised: 10/25/21
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