You may know that your bones can get less dense with age, after menopause or when you don’t do enough weight-bearing exercises or resistance training. What might not be so apparent is how the medications you take — for unrelated health conditions — might negatively impact your bone health.
A handful of commonly prescribed drugs used to treat everything from asthma attacks to breast and prostate cancer may decrease bone density and make fractures more likely. Being aware of these risks can give you the knowledge you need to advocate for your health and come up with a plan to prevent or minimize damage.
“Knowledge is power,” said Natasha Trentacosta, a board-certified orthopedic surgeon at Cedars-Sinai in Los Angeles. “When we understand the skeletal consequences of a necessary medication, we can take meaningful steps to protect bone health while continuing potentially lifesaving therapy.”
Below, she and other bone health experts explain what you need to know about five of these drugs.
Oral corticosteroids
Corticosteroids, such as prednisone, are used to reduce inflammation in the body. They’re commonly prescribed for a wide range of conditions, including lupus and other autoimmune diseases, asthma, rashes, severe allergies and musculoskeletal conditions such as tendinitis. They work by tamping down the body’s immune response.
These medications can impact bone health in a few different ways. They increase the activity of osteoclasts, which are cells that chew up bone and can interfere with calcium absorption, said Naim Maalouf, associate director of the Center for Mineral Metabolism and Clinical Research at the University of Texas Southwestern Medical Center.
Additionally, “they suppress the activity of osteoblasts, the cells responsible for building new bone, and can shorten the survival of both osteoblasts and osteocytes, which are essential for maintaining healthy bone structure,” Trentacosta said. “The result is a significant reduction in bone formation and the ability of bone to repair itself.”
In fact, the effects are so well documented that it’s known as “steroid-induced osteoporosis.”
A single short course of a week or two is generally not a major concern for bone health, said Maalouf. It may alter bone cells in the short term, but shouldn’t cause any lasting thinning or other damage. Higher daily doses and repeated prolonged exposure are what increase the risk of fractures and other bone issues, Trentacosta said. (Inhaled steroids, such as those used to treat chronic respiratory illnesses like asthma, may have a small impact on bone health depending on the dosage, frequency of use and other risk factors.)
Because of the clear risk that steroids pose to bone health, the American College of Rheumatology recommends anyone taking at least 2.5 mg of prednisone (or an equivalent drug) daily for more than three months be assessed for fracture risk, Trentacosta said.
“For patients at elevated fracture risk, medication to prevent bone loss may need to begin alongside steroid treatment rather than waiting until a fracture occurs or [bone density test] results become markedly abnormal,” Trentacosta said.
The right medication for you will depend on certain factors, including your fracture risk, co-occurring health conditions and any other medications you take, but the main options include bisphosphonates, denosumab and parathyroid hormone analogs.
Aromatase inhibitors
Aromatase inhibitors, such as anastrozole, letrozole and exemestane, are used to treat estrogen receptor-positive breast cancer and are known to cause bone density loss and increase fracture risk. They’re usually taken for an extended period of time, from about 5 to 10 years, depending on the specific cancer and patient.
These medications work by blocking an enzyme that’s needed for estrogen production. When estrogen levels fall dramatically, your body breaks down bone faster than it can rebuild it, Trentacosta said. “Over time, this imbalance leads to declining bone mineral density and an increased risk of fractures,” she said.
Research suggests that the lengthier the treatment, the greater the risks. And additional risk factors for low bone density, such as being postmenopausal, can compound the issues associated with these medications.
Anti-seizure medications
Anti-seizure medications, known as anticonvulsants, are drugs mainly used to treat seizures but are sometimes prescribed for other conditions, such as anxiety, nerve pain, bipolar disorder and migraine headaches.
There are dozens of drugs that fall into this category, and not all are bad for bone health, but some older anticonvulsants — including phenobarbital, phenytoin and carbamazepine — are most concerning, Maalouf said.
One side effect of these medications is that they can decrease vitamin D levels, which can interfere with your body’s ability to absorb calcium and can contribute to weak and thinning bones, Maalouf said. The drop in vitamin D levels can happen within weeks or months of starting on one of these medications, Maalouf says. But changes in bone density take a year or longer. “The ultimate impact is on higher fracture risk, which will be more apparent after years of treatment with these anticonvulsants,” Maalouf said.
Higher doses of these medications are associated with a greater decline in bone density and higher risk of fracture, Maalouf said.
Androgen deprivation therapy (ADT)
Androgen deprivation therapy (ADT) is a type of hormone therapy commonly used to treat prostate cancer. It works by lowering testosterone, which prostate cancer tumors need to grow. This can inhibit cancer growth, but testosterone also supports strong bones, so when levels drop, bones may get thinner and the risk of fractures can increase.
“Testosterone is also important for muscle health,” Maalouf said, so people may additionally lose muscle mass while taking this medication, putting them at higher risk for falls. “Independent of bone density, falling increases the risk of fracture,” Maalouf said.
Guidelines recommend that men who are starting long-term ADT have a bone density scan and undergo routine screening to measure bone mineral density throughout treatment. Men with low bone density or osteoporosis may be prescribed additional medications to protect bone health.
Selective serotonin reuptake inhibitors (SSRIs)
Selective serotonin reuptake inhibitors (SSRIs), often prescribed for depression and anxiety disorders, have been associated with a possible decrease in bone density and increased fracture risk.
Researchers aren’t entirely sure why SSRIs may affect bone health, and more research is needed. One theory is that SSRIs interfere with the functioning of osteoblasts, the cells required for growing new bones. This may lead to bone weakness and bone loss, said Daria Brooks Terrell, an orthopedic surgeon at the Center for Better Aging in Chicago.
In one study, researchers found that among people taking the SSRIs fluoxetine (Prozac), citalopram (Celexa) and sertraline (Zoloft), the risk of breaking a bone increased as the dose did. Taking SSRIs over a long period of time may also add to the risk, but the research findings are inconsistent, and it’s hard to say exactly what dosages and length of treatment are required to lead to bone issues.
“People taking these medications should get yearly bone scans while on treatment, as well as having calcium and vitamin D levels checked routinely,” Terrell said.
Talk with your doctor for guidance
While each of these medications may cause bone thinning or increase the risk of fractures, this doesn’t mean you need to avoid them entirely. If you already take any of these drugs, don’t stop on your own without consulting with the provider who prescribed it.
Instead, talk with them about any medications you’re concerned about and whether you should have a baseline bone density scan and potentially regular monitoring. Your provider can also recommend other protective steps, such as adding a medication to slow bone loss and ensuring you’re getting enough calcium and vitamin D (in your diet or from supplements if needed).
Regular weight-bearing activity and progressive resistance training are also important for maintaining bone and muscle health, Trentacosta said. “Strong muscles support balance, mobility, and physical function,” she said, “and they help reduce the likelihood of falls that can lead to devastating fractures.”
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