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Managing Bone Health With Bisphosphonate Drugs

Lupus is an autoimmune disease affecting bones and other body parts. Individuals with lupus may experience a higher risk of bone loss and broken bones (called fractures) due to inflammation and medication side effects.

Donald Thomas, MD author of The Lupus Encyclopedia for Gastrointestinal symptoms in lupus blog post

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

Bisphosphonate drugs have emerged as important tools in helping bone health for lupus patients. In this article, we’ll explore the role of bisphosphonates in lupus treatment and their benefits.

Understanding Managing Bone Health With Bisphosphonates

What Are Bisphosphonate Drugs?

Doctors commonly prescribe bisphosphonates, a class of medications, to treat conditions with weak bones, such as osteoporosis and bone metastases (cancer that spreads to the bones from other body areas). They work by slowing the body’s process of breaking down old bone (by cells called osteoclasts), known as bone resorption. This allows the cells that produce bone (osteoblasts) to form new, stronger bone.

Osteoporosis, Bisphosphonates and Lupus: Key Considerations

Preserving Bone Density: Why Is This Important?

Lupus patients are at a greater risk of bone loss due to factors like chronic inflammation and the use of drugs, like corticosteroids. Doctors use the term “osteoporosis” to describe bone with a higher risk of breaking due to having less bone density. Lupus patients develop broken bones from osteoporosis much more often than people who do not have lupus. Bisphosphonates are pivotal in preventing bone loss by slowing down the resorption process and making the bones stronger.

Treatment and Administration

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, while the IV form of ibandronate is given every 3 months.

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, 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. As of 2023, Atelvia now comes in a generic form, making it cheaper.

Benefits for Lupus Patients

Reduction in Fracture Risk

Lupus patients are more susceptible to fractures due to decreased bone density. Bisphosphonates effectively reduce the risk of fractures by maintaining bone strength and structure.

Balancing Corticosteroid Effects

Corticosteroids (like prednisone and methylprednisolone), often used to manage lupus inflammation, can lead to bone loss. Bisphosphonates counteract this effect by promoting bone formation, thus minimizing the impact of corticosteroid-induced bone weakening.

Empowering Patients with Knowledge About Managing Bone Health

Collaborative Decision-Making

Patients with lupus should collaborate closely with their healthcare providers to determine the suitability of bisphosphonate treatment. Healthcare providers consider factors such as disease severity, risk of fractures, and medication interactions.

Monitoring and Follow-Up

Regular bone density scans and monitoring are crucial to assess the effectiveness of bisphosphonates and make any necessary adjustments to the treatment plan.

Potential Side Effects

Gastrointestinal Upset

Oral bisphosphonates can sometimes cause gastrointestinal irritation. Advisors instruct patients to follow dosing guidelines and to stay upright for at least 30 to 60 minutes after taking the medication.

Osteonecrosis of the Jaw

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.”

Managing Bone Health

Bisphosphonate drugs play a vital role in managing bone health for lupus patients. These medications help preserve bone density, reduce fracture risk, and counteract the effects of corticosteroids on bone weakening. By collaborating with healthcare providers, staying informed about potential side effects, and undergoing regular monitoring, individuals with lupus can effectively navigate the complexities of bone health management. Always consult a medical professional before starting or changing any medication regimen.

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

For more detailed information on bisphosphonates, go to our other bisphosphonate blog post:

For more in-depth information on bisphosphonate drugs and other medicines used to treat osteoporosis:

Read chapters 24 of The Lupus Encyclopedia, edition 2

Look up your symptoms, conditions, and medications in the Index of The Lupus Encyclopedia

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What are your comments and opinions?

If you have osteoporosis and lupus, what has your experience been? What do you recommend for other patients?

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Edited by and expanded by Donald Thomas, MD


  1. 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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