A Guide to Osteoporosis Medications in Canada: Options, Risks, and Benefits

Bone health is a frequent and important focus of conversations in our clinic. Many women are acutely aware of how declines in bone density, or the experience of a fracture, can significantly affect their overall health, independence, and quality of life.

One topic that commonly arises is the role of medications. There are multiple medication options and treatment strategies available for both the prevention and management of bone loss, and understanding these choices is an essential part of informed bone-health care.

In this post, we will review the range of medications used in bone health, how they work, and their potential benefits and risks.

Who Should Consider Pharmacologic Therapy?

Navigating when to start medication can be confusing. Currently, Canadian guidelines recommend pharmacologic therapy for:

• Postmenopausal women diagnosed with osteoporosis based on DXA bone mineral density testing.
• OR Women aged 65 years and older with T-score values below −2.0.

Key Factors We Consider Before Prescribing

Medication is never a one-size-fits-all solution. When we look at prescribing options, we consider several individual factors to ensure the treatment plan aligns with your specific needs:

• Fracture Risk: We often use tools like FRAX to assess your 10-year risk of fracture, taking into account factors like age, weight, parental hip fracture history, and lifestyle factors like smoking or alcohol use.
• Bone Mineral Density (BMD): Your T-scores from initial testing help guide the intensity of the treatment needed.
• Medical History: We look for existing vertebral fractures (often identified via x-ray) and patient-specific factors such as menopausal status and medication history.
• Personal Preference: Your comfort level matters. We discuss administration routes (daily pills vs. infrequent injections) and your specific goals—whether that is improving density, reducing fracture risk, or both.

Overview of Medications for Bone Health

There are several options available in Canada for the prevention and treatment of osteoporosis. Here is an overview of the most common therapies.

1. Bisphosphonates (First-Line Therapy)

Bisphosphonates are among the most commonly prescribed and well-studied treatments. They have been used for decades and are considered a cornerstone of osteoporosis therapy.

• Common Options: Alendronate (Fosamax®) and Risedronate (Actonel®) are oral options. Zoledronic acid (Reclast®) is an intravenous option often used when oral medications are not tolerated.
• Effectiveness: They are highly effective at reducing fracture risk, particularly for vertebral, non-vertebral, and hip fractures.
• Safety Protocol: To maximize absorption and safety, patients must take oral medication first thing in the morning with a full glass of water and remain upright for at least 30 minutes.

Potential Side Effects: While generally well-tolerated, some patients experience gastrointestinal symptoms like reflux or nausea, or musculoskeletal discomfort. Rare risks include osteonecrosis of the jaw (ONJ) or atypical femur fractures, though these are uncommon (e.g., the risk of atypical fracture is approximately 0.002% after 2 years of treatment).

2. Denosumab (Second-Line Therapy)

Denosumab is typically prescribed when bisphosphonates are contraindicated or not tolerated. It is administered as a 60 mg subcutaneous injection every six months.

• Benefits: It offers efficacy comparable to bisphosphonates regarding fracture risk reduction and is generally well-tolerated.
• Important Considerations: This medication is not recommended for premenopausal women or general prevention. Crucially, if Denosumab is stopped, there is a risk of rapid bone loss and increased compression fractures. Therefore, if you stop this medication, you must transition to an alternate agent immediately.

3. Systemic Estrogen Therapy (Preventive)

Systemic estrogen therapy has been shown to effectively prevent bone loss in postmenopausal women. It is most often prescribed when there are additional benefits, such as relief from menopausal symptoms like hot flashes.

• Limitations: Estrogen is not approved for the treatment of established osteoporosis and has not been proven to reduce fracture risk in women who already have the condition.
• Discontinuation: Bone-protective effects are lost within months after stopping therapy, so ongoing treatment is required to maintain benefits.

Making an Informed Decision

There is much to consider when choosing the right medication. Determining which option is the best fit depends on individual risk factors, preferences, and goals.

If you would like more guidance or clarification, please don’t hesitate to reach out. We are happy to review all available options and help you make an informed decision.

What Else Actually Helps Your Bones?

Medication is only one piece of the puzzle. Daily habits matter more than most people realize.

Nutrition Matters: Bones need building materials. Calcium, vitamin D, protein, magnesium, and vitamin K2 all play roles in bone structure and mineral balance. In Canada, vitamin D supplementation is commonly needed year-round.

Strength Training Is Powerful: Bones respond to load. Resistance training and weight-bearing exercise help maintain bone density and reduce fall risk by improving muscle strength and balance.

Fall Prevention Is Fracture Prevention: Balance training, good footwear, regular vision checks, and simple home safety changes can dramatically reduce fracture risk.

Sleep and Hormones Matter: Poor sleep and menopausal hormone changes both affect bone turnover. Supporting sleep quality and recovery is an underrated bone-health strategy.

Lifestyle Habits Add Up: Smoking, excess alcohol intake, and chronic under-eating all accelerate bone loss. Small changes here create long-term impact.

The Big Picture

Osteoporosis care is not just about scans and prescriptions — it’s about protecting strength, independence, and quality of life as you age.

If you’re unsure where you fall on the bone health spectrum, or want help understanding your options, personalized guidance makes all the difference.

References

1. North American Menopause Society (NAMS). The 2022 Hormone Therapy Position Statement of The North American Menopause Society. Menopause. 2022.
2. Osteoporosis Canada. 2023 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada.
3. Kanis JA, et al. FRAX® and fracture prediction without bone mineral density. Osteoporosis International. 2011.
4. Reid IR, et al. Efficacy and safety of bisphosphonates in the treatment of osteoporosis. The Lancet. 2015.
5. Cummings SR, et al. Denosumab for prevention of fractures in postmenopausal women with osteoporosis. New England Journal of Medicine. 2009.
6. Eastell R, et al. Management of endocrine disease: Long-term safety of osteoporosis therapies. European Journal of Endocrinology. 2018.
7. Compston J, et al. Effects of discontinuing denosumab treatment: A systematic review. Bone. 2017.
8. Weaver CM, et al. Calcium plus vitamin D supplementation and fracture prevention. New England Journal of Medicine. 2016.