Medications and Osteoporosis Risk: How to Protect Your Bones

Cortisone for rheumatism, an acid blocker for heartburn, an antiepileptic for years — many long-term medicines are indispensable, and some of them weaken the bones along the way or increase the risk of falling. That is no reason to leave tablets out. It is, however, a good reason to actively discuss your bone risk with your practice before a fracture forces the issue. This guide shows you which active substances are relevant, how solid the evidence is in each case and what you can do in concrete terms.

1. Two routes to a broken bone: bone mass and falls

Osteoporosis (bone loss) means that bone loses mass and internal structure and can break even under everyday loads — typically in the vertebrae, hip, wrist and upper arm.¹ Bone is a tissue that is constantly being remodelled. Medicines can shift this balance: they slow down bone formation, speed up bone breakdown or disturb the calcium and vitamin D balance.

The second, often overlooked route: medicines that make you dizzy or tired, or make your blood pressure drop when you stand up, increase the risk of falling. A fracture needs both — a weakened bone and a force acting on it. Most hip fractures in older age happen during a fall.

How the condition itself is diagnosed and treated is described in the article Osteoporosis. Here the focus is on the narrower question of what role your medicines play. The good news: medication-related bone loss is often predictable — you know when the strain begins and can take countermeasures right from the start.

2. Cortisone: the biggest bone thief among medicines

Glucocorticoids such as prednisolone are often indispensable for rheumatism, asthma flare-ups or inflammatory bowel disease. They harm bone in several ways: they inhibit the bone-forming cells (the main effect), reduce calcium absorption in the gut and, if taken for a longer time, can break down muscle in the thighs and hips — which also makes you less steady on your feet.

Timing is crucial: bone loss is greatest in the first months of treatment, and the fracture risk rises early — sometimes even before a bone density scan is clearly abnormal. The vertebrae are particularly affected. According to the DVO guideline (Dachverband Osteologie, the German umbrella organisation for osteology), taking a low dose for more than three months already counts as a risk factor; with a higher dose and a longer duration, the risk rises further. Repeated short high-dose courses add up too.¹ After stopping, the increased fracture risk partly recedes again.

Tablet, spray, injection, cream — not every form is the same

• Tablets and infusions act throughout the body — this is where the real bone risk lies.
• Inhaled preparations such as budesonide play a considerably smaller role at usual doses, according to current evidence; very high doses over years can contribute. Well-controlled asthma without cortisone tablets is usually the better balance for your bones.
• Joint injections hardly matter individually, but frequent repeats add up. Creams and nasal sprays are, as a rule, negligible when used normally.

The most important consequence: if cortisone treatment is planned for more than three months, the bone question belongs at the very start. The guideline then provides for an estimate of the fracture risk; depending on the result, bone-protecting treatment may make sense right from the beginning.¹ Which cortisone worries are justified is put into perspective in the article Cortisone: myths and facts.

3. Acid blockers (PPIs): a small risk, a great many people affected

Proton pump inhibitors (PPIs, acid blockers) such as pantoprazole, omeprazole or esomeprazole are among the most frequently taken medicines of all — some of them available without a prescription. The summaries of product characteristics contain a warning: if PPIs are taken at high doses and for more than a year, the risk of fractures of the hip, wrist and spine may rise slightly, especially in older people and in the presence of other risk factors.³

Put honestly, that means:

• The data come mainly from observational studies. Whether the acid blockers themselves are the cause has not been proven. People on long-term PPIs are older on average and have more accompanying illnesses — that alone explains part of the effect.
• Mechanisms under discussion: less stomach acid can impair the absorption of calcium from certain compounds. In addition, PPIs taken for a longer time can cause magnesium deficiency — according to the summary of product characteristics, usually after at least three months, and in most cases after about a year.³
• For you as an individual, the additional risk is small. It becomes relevant because a great many people take PPIs for years — often even though the original reason has long since gone.

What follows from this is not fear, but a question for your practice: do I still need the acid blocker — and at this dose? Some people need it permanently, for example with severe reflux disease or as stomach protection when blood thinners and painkillers are taken together. Others manage with a lower dose or by taking it only when needed. Background in the article Heartburn.

4. Antiepileptics: when vitamin D is used up faster

Medicines for seizures are often taken for decades. The effect on bone is particularly well documented for the enzyme inducers — active substances such as carbamazepine, phenytoin, phenobarbital and primidone, which boost liver enzymes. These enzymes also break down vitamin D faster. The result can be low vitamin D levels, poorer calcium absorption and, in extreme cases, softening of the bones (osteomalacia). Lower bone density has also been described for valproic acid, in this case through other mechanisms.⁴

Newer active substances such as levetiracetam or lamotrigine are considered less problematic based on the data so far; however, the evidence is limited. Whatever the active substance: seizures themselves lead to falls, and so do side effects such as dizziness.

Antiepileptics are not only used for epilepsy: carbamazepine is a standard treatment for trigeminal neuralgia, and valproic acid is also used in psychiatry. The bone issue is the same — it is just raised less often.

• Raise vitamin D and bone density — with many years of treatment with enzyme inducers, a check is often worthwhile, especially if there are other risk factors. Whether and how often is decided by your practice.
• Never switch or reduce on your own — a seizure is more dangerous than any side effect. Changing the active substance is a medical decision.

5. Other active substances that affect bone: an overview

For further medicines an effect on bone is known or under discussion — the strength of the evidence differs considerably.^1,3

With thyroid hormone it is about the dose, not the medicine: correctly adjusted, levothyroxine poses no problem for the bones. Which other medicines shift the TSH level is explained in the guide Medications and thyroid tests. A counterexample shows that hardly any medicine is simply “good” or “bad”: thiazide diuretics such as hydrochlorothiazide reduce calcium excretion and tend to be associated with slightly higher bone density — but by lowering blood pressure and causing sodium deficiency, they can make falls more likely in older people.

6. Medicines that promote falls: the underestimated half

Whether a bone actually breaks often depends on whether someone falls. Here other active substances play the leading role — those that make you tired, disturb your balance or weaken your circulation when you stand up. The PRISCUS 2.0 list, which compiles medicines that carry a particular risk for older people, includes many of them.⁵

• Sedatives and sleeping pills: benzodiazepines such as lorazepam and Z-drugs such as zolpidem — drowsiness and unsteadiness can last into the next day.
• Sedating antidepressants and antipsychotics: tiredness, a drop in blood pressure when standing up.
• Opioids: drowsiness, especially at the start and after dose increases.
• Blood pressure medicines and water tablets: dizziness when standing up, trips to the toilet at night in the dark.
• Medicines with anticholinergic effects: for example older antihistamines or bladder medicines such as oxybutynin — confusion, blurred vision.

The sheer number counts as well: people who take many medicines at the same time fall more often — regardless of which ones they are in detail. How to limit this effect is described in the guide Dizziness from medications. If sleeping pills or sedatives are an issue for you, the article Sedatives: alternatives to benzodiazepines shows which options there are — and why stopping always has to be done slowly.

• Get up slowly — sit first, wait briefly, then stand. At night, make sure there is light and a clear path.
• Keep an eye on new tablets — after starting or increasing the dose of a medicine that makes you tired, be particularly careful and note down anything unusual.

7. Step by step: how to clarify your bone risk

You do not have to calculate your risk yourself. But you can make sure that someone does it at all. Here is how to go about it:

1. Draw up a complete list. All medicines, including sprays, injections and over-the-counter products — acid blockers are often bought without a prescription. Food supplements belong on it too. Instructions in the guide Creating a medication plan.
2. Note duration and dose. Since when, and at what strength? With cortisone, the short high-dose courses of recent years count too.
3. Gather other risk factors. Previous fractures without a major accident, a hip fracture in your mother or father, smoking, being underweight, falls in the past year, conditions such as rheumatism or type 1 diabetes.
4. Ask specific questions at your practice. Do I still need every medicine? Can the dose be lower? Are there more bone-friendly alternatives? Would a bone density scan make sense?
5. Put the bone density scan in context. The DXA scan (dual-energy X-ray absorptiometry) is a short X-ray procedure with low radiation exposure — but only one piece of the puzzle: the guideline estimates the fracture risk from the measurement, age, sex and risk factors together.¹
6. Clarify the cost question beforehand. Statutory health insurers usually cover the scan if there are specific findings — such as a fracture without a corresponding accident — and drug treatment is being considered. As a purely preventive check, it is often a self-pay service.^2,6

8. Basic protection: what has been shown to help — and what has not

Regardless of whether you later need an osteoporosis medicine: the basics apply to everyone whose bones are under strain from medicines.^1,2

• Calcium from food: as a guide, the DVO guideline names a total intake of about 1,000 milligrams per day — ideally from dairy products, hard cheese, green vegetables or calcium-rich mineral water (more than 150 milligrams per litre). Supplements only if your diet is not enough. On acid blockers, calcium carbonate is absorbed less well than calcium citrate — the pharmacy can tell you which form suits you.
• Correct vitamin D, do not overdose: for people at increased risk, the guideline names 800 to 1,000 international units a day as a guide value if the body’s own production from sunlight is not enough. Your practice will clarify whether that applies to you. Risks of high-dose preparations in the article Vitamin D.
• Exercise: strength training, brisk walking and above all balance exercises strengthen bones and muscles and lower the risk of falling. Taking it easy speeds up bone loss. Physiotherapy or Reha-Sport (rehabilitation exercise groups) are a good way to start.
• Further adjustments: do not smoke, limit alcohol, avoid being underweight and, in older age, make sure you get enough protein.

9. When an osteoporosis medicine is added

If the fracture risk is high, your practice may additionally prescribe a medicine that acts on bone. Which one is suitable depends on the risk, kidney function, accompanying illnesses and your preferences — this decision lies with the practice treating you.¹

Before bisphosphonates and denosumab, it makes sense to have your teeth looked at: very rarely, osteonecrosis of the jaw (dying jawbone) can occur, especially after tooth extractions. A dental check-up before starting treatment lowers the risk — see Medications and dental health. And: calcium, magnesium and iron bind bisphosphonates, levothyroxine and certain antibiotics in the gut. If you take several of these, you need a schedule — otherwise the tablet does not get where it needs to go.

10. Special groups

• Women after the menopause: with the drop in oestrogen, bone loss speeds up anyway. If cortisone, aromatase inhibitors or long-term PPIs are added, the effects add up. More in the article Menopause.
• Men: osteoporosis is seen as a women’s issue and in men is often only recognised after the first fracture. Cortisone, hormone deprivation for prostate cancer, alcohol and antiepileptics are typical triggers — ask about it actively.
• Older people: the risk of falling counts at least as much as bone density. Every new tablet should be checked for whether it makes you tired or dizzy — see Medications in old age.
• Children and adolescents: peak bone mass is built up until young adulthood. Longer courses of cortisone or antiepileptics are monitored particularly closely by the paediatric practice.
• Pregnancy: if heparin has to be injected for months, a low-molecular-weight heparin, which puts less strain on the bones, is usually chosen.
• Chronic inflammatory diseases: in rheumatoid arthritis, Crohn’s disease or COPD, the disease and cortisone both act on bone. Well-controlled inflammation is itself a form of bone protection.

11. How brite helps you protect your bones

Bone protection in your medication plan — with brite

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