published by nonprofit Johns Hopkins Press
posted in Drugs used in lupus on September 5, 2023 by
Updated February 15, 2025
Individuals with systemic lupus erythematosus (SLE) are at increased risk of broken bones (fractures) due to osteoporosis. Increasing bone strength with bisphosphonate drugs is important. This article discusses bisphosphonate drugs used in lupus patients.
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NOTE: Johns Hopkins University Press, publisher of The Lupus Encyclopedia, is a nonprofit publisher. If you purchase JHUP books, like The Lupus Encyclopedia, you support projects like Project MUSE.
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This blog on “Managing Bone Health With Bisphosphonate Drugs” was edited and contributed to by Donald Thomas, MD; author of “The Lupus Encyclopedia.” Parts of this blog post come from “The Lupus Encyclopedia: A Comprehensive Guide for Patients and Health Care Providers, edition 2“
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Bisphosphonate drugs have emerged as important tools in helping bone health for lupus patients.
Doctors commonly prescribe bisphosphonates, a class of medications, to treat weak bones, such as osteoporosis, Paget’s disease, and bone metastases (cancer that spreads to the bones from other body areas). They work by preventing the body from breaking down old bone by cells called osteoclasts. This allows cells that produce bone (osteoblasts) to form new, stronger bone.
Lupus patients are at a greater risk of bone loss due to factors like chronic inflammation, inactivity from pain and fatigue, and from drugs, like steroids. Doctors use the term “osteoporosis” to describe bone with a higher risk of breaking due to low bone density. Lupus patients develop broken bones from osteoporosis much more often than people who do not have lupus.
You can take bisphosphonates orally or intravenously (IV). Popular oral options include alendronate (Fosamax), ibandronate (Boniva), and risedronate (Actonel). The IV form, zoledronic acid (Reclast), is usually given once a year.
Most of the oral forms must be taken on an empty stomach in the morning with a full glass of water. No food, drink (other than water), or other drugs can be taken for 30 to 60 minutes after taking them. Even a sip of coffee can reduce their absorption (hence the reason for no food, drink, or drugs). Also, it is important to not lie down for 30 – 60 minutes after taking them. If they go back up into the esophagus while lying down, they could irritate the esophagus (the tube that connects the mouth and stomach).
Atelvia, a slowly released form of risedronate, is designed to be taken with breakfast. However, it is still important to not lie down afterward. Atelvia now comes in a generic form, making it cheaper.
Bisphosphonates reduce the risk of fractures by improving bone strength and structure.
Steroids (like prednisone and methylprednisolone), often used to treat lupus, can lead to bone loss. Bisphosphonates counteract this effect by promoting bone formation, thus minimizing the impact of steroid-induced bone weakening.
Patients with lupus should collaborate closely with their healthcare providers to determine the suitability of bisphosphonates. Healthcare providers consider factors such as disease severity, risk of fractures, other medical problems (such as the ability to swallow), and medication interactions.
Regular bone density scans (DXA scans) measure the effectiveness of bisphosphonates. Doctors typically order a DXA scan every 1-2 years on bisphosphonate treatment and make necessary adjustments if needed.
Not everyone tolerates bisphosphonates, and they do not work in everyone. In these cases, your doctor may prescribe a different osteoporosis drug. Examples include denosumab (Prolia), teriparatide (Forteo), abaloparatide (Tymlos), romosozumab (Evenity), and raloxifene. You can read about these and the bisphosphonates in much greater detail in chapter 24 of The Lupus Encyclopedia. I also placed a comprehensive description on another bisphosphonate blog article page: https://www.lupusencyclopedia.com/bisphosphonate-drugs-and-lupus/
Oral bisphosphonates can sometimes cause gastrointestinal irritation, especially in the esophagus. Typical symptoms include heart burn, trouble swallowing, and chest pain. Immediately report these to your doctor if they occur after beginning bisphosphonate therapy. Following the instructions above greatly reduce this risk.
Around 10% of patients given IV Reclast can develop body aches and low grade fever due to systemic inflammation caused by the drug. I ask my patients to take acetaminophen (Tylenol) at the maximum dose and around the clock for a few days after their infusion to prevent this from occurring. An example is acetaminophen 650 mg tablets (Tylenol Arthritis), 2 tablets at a time three times daily for 3-5 days after the infusion. Take the first dose right after the infusion (or ask the infusion nurse for the best timing). If you were given acetaminophen as a “premed” before the infusion, they you may need to wait 4-7 hours after the infusion before taking your first dose. Ask your doctor before taking acetaminophen. Patients with severe liver disease should not take it.
Although rare, there have been cases of osteonecrosis of the jaw associated with bisphosphonate use. Patients should inform their dentist and oral surgeon before undergoing dental procedures.
Another rare side effect is called atypical femoral fractures.
Both of these (atypical fractures and osteonecrosis of the jaw) are usually prevented by using bisphosphonates for a short period of time (3-5 years), then stopping them for a while for what doctors call a “drug holiday.”
For more detailed information on bisphosphonates, go to our other bisphosphonate blog post: https://www.lupusencyclopedia.com/bisphosphonate-drugs-and-lupus/
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Read chapters 24 of The Lupus Encyclopedia, edition 2
Look up your symptoms, conditions, and medications in the Index of The Lupus Encyclopedia
If you enjoy the information from The Lupus Encyclopedia, please click the “SUPPORT” button at the top of the page to learn how you can help.
If you have osteoporosis and lupus, what has your experience been? What do you recommend for other patients?
Do you have any questions to ask Dr. Thomas?
Please click on “Leave a Comment” above to comment.
Click on “SUPPORT” at the top of the page to learn how you can support “The Lupus Encyclopedia“
Read more in The Lupus Encyclopedia, edition 2
Look up your symptoms, conditions, and medications in the Index of The Lupus Encyclopedia
If you enjoy the information from The Lupus Encyclopedia, please click the “SUPPORT” button at the top of the page to learn how you can help.
If you have lupus, what has your experience been? What do you recommend for other patients?
Do you have any questions to ask Dr. Thomas?
Please click on “Leave a Comment” above to comment.
Click on “SUPPORT” at the top of the page to learn how you can support “The Lupus Encyclopedia“
The information in the “managing bone health” only talks About bio phosphates. I am currently on Prolia. No side effects. Much greater effectiveness at managing osteoporosis! My rheumatologist specializes in management of osteoporosis. She put my mom on Prolia a decade ago. It’s not a new treatment, however, it is far superior to bio phosphates. It’s good to keep up-to-date with osteoporosis treatment especially for lupus patients.
Susan: thanks for your comment. My article is specifically about bisphosphonates (I go into much greater detail about all the medications in the chapter on osteoporosis in my book). I did not have time nor space to discuss all our osteoporosis therapies.
Denosumab (Prolia) is an excellent agent, however it has not been proven to be “far superior.” A 2019 meta-analysis of 107 research studies found denosumab to have slightly increased numbers for decreasing vertebral and hip fractures. However, the authors of the meta-analysis pointed out that the data were limited due to the lack of significant head-to-head studies.
I am glad your mom is doing well on Prolia. However, all osteoporosis expert guidelines recommend bisphosphonates as the first drugs of choice (alendronate is preferred, risedronate is least preferred) due to their long term proven effectiveness since being used in the 1990s (when used correctly and when people are given drug holidays to prevent side effects). Then therapies like Prolia are used in patients who do not tolerate them or cannot take them for certain reasons.
Experts’ hesitancy regarding Prolia as a first line agent is that if someone is late on getting their Prolia, there can be rapid loss of bone density and subsequent rapid onset of multiple vertebral fractures. This is not to be taken lightly and can be catastrophic. As physician, we see lapses in followup even among our best patients (for example, let’s say someone gets quite ill and is unable to come in for their Prolia due to reasons beyond their control … that can be quite dangerous).
again, thanks for your comment. There are many excellent osteoporosis drugs (we should also mention romosozumab and the PTH analogues like Forteo and Tymlos). Hopefully, I’ll have time to also do posts about them, but at this time I do discuss them all in detail in my book. I just wish I had more time to do more online blog posts.
Happy Holidays, and I hope your mom continues to do well!
Donald Thomas, MD
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