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A Comprehensive List of Medications that Cause Osteoporosis

At-a-Glance:

  • The most commonly prescribed medications damage bone.
  • Medications strip bones of minerals, destroy collagen, and increase the risk of osteoporosis, falls, and fractures.
  • Talk to your doctor and pharmacist if you take any medications, especially any of the drugs below.
Anxiety Word Cloud

By Dr. John Neustadt

The most commonly prescribed medications strip bones of minerals, damage collagen, and increase the risk of osteoporosis, falls, and fractures.1 Not all drugs increase a person’s risks equally. It can depend on the dose, your age, how long you take it, and whether you’re on multiple medications. 

This is a dangerous and important issue everyone needs to know about. I’ve lectured at medical conferences to educate physicians on this, and it is included in a chapter in my book, Fracture-Proof Your Bones. Talk to your doctor and pharmacist if you take any medications, especially any of the drugs below. This is not an all-inclusive list. 

Acid blockers: Protonix, Prilosec, Tagamet

Androgen-deprivation therapy (ADT): leuprolide (Lupron), goserelin (Zoladex), triptorelin (Trelstar), histrelin (Vantas)

Antidepressants: citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft), atomoxetine (Strattera), desvenlafaxine (Pristiq), duloxetine (Cymbalta), and venlafaxine (Effexor XR)

Antipsychotics: Aripiprazole (Abilify, Aristada), asenapine (Scuado, Saphris), clozapine, lumateperone (Caplyta), lurasidone (Latuda), olanzapine (Zyprexa, Symbyax), quetiapine (Seroquel), paliperoidone (Invega), pimavanserin (Nuplazid), risperidone (Perseris, Risperdal), haloperidol (Haldol), chlorpromazine, fluphenazine, 

Antiseizure meds: Phenobarbital, Phenytek, Dilantin (phenytoin), Tegretol, Carbatrol (carbamazepine), Topamax (topiramate), Trileptal, Ostellar (oxcarbazepine), Valproate (when taken for 36 months or longer) 

Aromatase inhibitors: Letrozole, Anastrazole, Exemestane 

Blood pressure meds: All blood pressure medications

Chemotherapy: cyclophosphamide, methotrexate, ifosfamide, alkylating agents, tamoxifen (pre-menopausal use)

Depot medroxyprogesterone acetate (DMPA)

Diabetes meds: Thiazolidinedione (TZD) 

Glucocorticoids: Prednisone, Dexamethasone, Prednisolone, Budesonide, Cortisone, Methylprednisolone, Betamethasone, Beclomethasone

Heparin

Hypnotics (e.g., for anxiety and sleep): alprazolam (Xanax), temazepam (Restoril), clonazepam (Klonopin), zolpidem (Ambien), zaleplon (Sonata). 

Immunosuppressants: Cyclosporin, Tacrolimus, 

Muscle relaxants: baclofen (Fleqsuvy, Ozobax, Lyvispah), cyclobenzaprine (Amrix, Fexmid, Flxeril), tizanidine (Zanaflex)

Opioids: increase fall risk

Thyroid hormone: when dosed too high, it causes hyperthyroidism and damages bones.

Acid Blockers

In 2010, the FDA warned about taking acid-blocking medications and fracture risk. The agency found that although over-the-counter doses for two weeks or less did not present a risk, individuals taking higher doses of proton pump inhibitors (PPIs) such as Protonix, Prilosec, and Omeprazole or using them for a year or more had a higher risk of osteoporosis and fractures.2 Taking a PPI for one year is associated with a 22% increase in hip fracture risk, which climbs each year: 41% after two years, 54% after three years, and 59% after four years.3 Since then, many studies looking at hundreds of thousands of patients have confirmed the association between PPI use and fractures of the spine, hips, and other bones.4-6

If you’re taking these medications, the good news is that you might not need them. If you take it for acid reflux, simple dietary changes can reduce acid symptoms and may allow you to reduce the dose or discontinue the medication.  

Talk to your doctor about this and whether you even needed the medication in the first place. Multiple studies have shown that acid blocking medications are often inappropriately prescribed. A study from New Zealand found that 40% of hospital patients taking proton pump inhibitors did not need them.7 Another study in Wales found that one out of every four hospital patients took a proton pump inhibitor, but the medication was appropriate for only half of them.8  Other researchers have concluded that up to 75% of all PPI prescriptions have no appropriate indication.9  

If you have to take an acid blocker, the histamine-2 receptor antagonists (H2RA) appear to be safer than the PPIs. H2RA drugs include Pepcid, Tagamet, and Zantac. Studies show no association between H2RA medications and fractures.10, 11 

Antidepressants

Approximately 25 million adults have been on antidepressants for over two years, and another 15 million have been on the medications for at least five years.12 The most popular—serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs)—are prescribed for depression, anxiety, fibromyalgia, premenstrual syndrome, and more. 

Serotonin is commonly understood to be one of your brain’s happy hormones, which is how these medications improve mood. However, 95% of serotonin is produced in your intestines. Platelets then carry the serotonin around the body but never enter the brain. Instead, it exerts its actions on other tissues, including bone. Serotonin receptors in bone decrease bone formation and increase bone breakdown.13-16 

When serotonin is artificially elevated by SSRI and SNRI medications, it destroys bone, creates osteoporosis, and increases fracture risk. Elderly women taking an SSRI have a 60% faster rate of bone loss compared to people not taking them.17  

However, a review of 23 studies determined that, regardless of a person’s age, patients taking SSRIs have a 67% increased risk of fractures. Like with other drugs, the longer someone takes the medication, the greater their risk. The researchers also discovered that after just one year of taking these medications, one person would be expected to break a bone for every 85 people taking the drug. After five years on the medication, for every 19 patients taking them, one will experience a fracture.18

It’s not just the SSRIs that damage bone. A ten-year study of 6,645 Canadians concluded that SSRIs and SNRIs are both associated with an increased fracture risk.19 

Antiseizure medications

Osteoporosis affects up to 31% of people with epilepsy, and people taking antiseizure medications are two to six times more likely to break a bone compared to people not taking these drugs.20  

While not all antiseizure medications damage bone, those that do adhere to the same pattern seen with other medications: the higher the dose and the longer someone takes the medication, the greater the risks. The odds of a fracture increase by 4-6% for every year someone takes one of these medications.21 When people take multiple antiseizure medications, their risk also goes up. Taking two antiseizure medications compared to one in 230%.22 

Importantly, not all epilepsy medications seem to cause bone loss and osteoporosis. While data are limited, research shows that Lamictal (lamotrigine) does not seem to damage bones or increase fracture risk.23 However, valproate can, but only when taken for 36 months or longer.24

People taking these medications should talk to their doctor about getting screened for bone loss. Current recommendations include getting tested with a bone density test when someone is on a high dose of one of these medications, if they take two or more, or if they take another medication known to cause bone loss. Testing vitamin D and taking a vitamin D and calcium dietary supplement are also recommended.20

Aromatase Inhibitors

Aromatase inhibitors (AIs) block estrogen production and are one of the top-prescribed drugs for postmenopausal women with estrogen receptor-positive (ER-positive) cancers.25, 26 Once a woman starts an AI, it’s common for her to continue taking it for many years. Bone loss in women with breast cancer is a major concern. Up to 80% of all breast cancer patients lose bone.27, 28 Plus, breast cancer patients who are hospitalized with a fracture have an 83% higher risk of dying compared to breast cancer patients who don’t break a bone.29  

Estrogen naturally decreases during menopause, increasing how fast bone is lost. However, taking an AI increases bone loss up to four times faster. After five years of taking an AI, one in every five patients—an alarming 20%—breaks a bone.30  

Even though the National Comprehensive Cancer Network and the American Society for Clinical Oncology (ASCO) recommend all breast cancer patients taking an AI get bone density tests, many don’t. Only 42% to 68% of all women starting this treatment get a bone density test.31-35 So make sure you ask for a bone density test and track your bone health with repeat testing.

Glucocorticoids

Glucocorticoids powerfully suppress inflammation and modulate the immune system. These medications are so popular that an estimated 1-2% of the general population take them long-term, meaning for months and years.36 However, nearly 5% of women with postmenopausal osteoporosis—who should definitely try to avoid medications that weaken bones—are on these drugs.37, 38 

Glucocorticoids are so dangerous that fractures occur in up to 50% of patients who take them long-term.39 They’re such potent bone destroyers that even taking less than 2.5 mg/day over just six months increases fracture risk up to 200% compared to people not taking them.40 One study found that every time a patient’s dose increases by as little as 10 mg, their fracture risk increases by a whopping 62%.41  

Until recently, it was generally accepted that only people chronically taking the drugs (for months or longer) were at risk. But we now know that even taking them for as little as six days can cause problems. A 2017 study concluded that people who took these medications had an 87% higher chance of breaking a bone compared to people who hadn’t taken the medication.42 

Fortunately, fracture risk declines after discontinuing the glucocorticoids. However, we don’t know whether your bones will return to their pre-medication strength.40, 43-45 

One of the challenges in helping patients who take glucocorticoids is that fracture risk increases before we can detect changes in BMD.41 If you’re on a glucocorticoid and your bone density is normal, you and your doctor should assume that damage is still occurring. Even with this limitation, I recommend patients get a bone density test before starting long-term glucocorticoid treatment and then track their bone health with follow-up bone density testing.

High Blood Pressure Meds

Maintaining healthy blood pressure is important for cardiovascular health. If one of these medications decreases your blood pressure too much, it can create dizziness and imbalance. This increases your risk of falls and fractures. Making sure you’re on the proper dose is important for safely taking these drugs. The risk is higher when someone takes two or more of these medicines.46 If you’re taking any blood pressure medication, you should regularly monitor your blood pressure and ensure it’s within the target range set by your doctor.  

If you take other medications, you might want to talk to your doctor and pharmacist to ensure that one of them isn’t causing your high blood pressure. A 2021 study concluded that nearly 15% of adults in the USA use medications that elevate blood pressure, and 18.5% of people with diagnosed hypertension are taking a medication that causes high blood pressure.47 

Hypnotics

These are typically prescribed for difficulty sleeping, anxiety, and panic disorders. These powerful psychiatric medications suppress the activity of the central nervous system. While they help people feel calmer and sleep, they can also decrease alertness and cause dizziness and lightheadedness the next day. Additionally, they can increase the risk of accidents and falls and have been associated with other health issues.48, 49 

A 2018 study concluded that just one of these medications, Ambien, accounted for 11.5% of all hospital emergency department visits caused by psychiatric meds.50 Since the ability of the body to clear the drugs decreases as people get older, the elderly are particularly at risk for side effects.  

A systematic review and meta-analysis of data from eighteen studies with patients 72 to 84 years old concluded that taking any of these medications increased fracture risk by up to 240% compared to people not taking them.51 

Muscle relaxants

Like hypnotics, opioids, and antihypertensive medications, muscle relaxants increase the risk of falls and fractures, especially in older adults.52 A study of people 50 years and older determined that 27.8% of them who took baclofen and 29.2% who took tizanidine fell.53 A review of Medicare Advantage patient data concluded that taking a muscle relaxant was associated with a 40% increase in fracture risk compared to people not taking one.54

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References

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2 FDA Drug Safety Communication: Possible increased risk of fractures of the hip, wrist, and spine with the use of proton pump inhibitors. US Food and Drug Administration. 

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8 Batuwitage BT, Kingham JG, Morgan NE, et al. 2007;83(975):66-8. 

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12 Carey B, Gebeloff R. Many People Taking Antidepressants Discover They Cannot Quit. New York Times. 2018. April 7, 2018. April 20, 2021. Accessed April 20, 2021. 

13 Kelly RR, McDonald LT, Jensen NR, 2019;10:200.

14 Wadhwa R, Kumar M, Talegaonkar S, et al. 2017;3(2):75-81. 

15 Abid S, Houssaini A, Chevarin C, et al. 2012;303(6):L500-L508. 

16 Bliziotes M, Eshleman A, Burt-Pichat B, et al. 2006;39(6):1313-21. 

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18 Khanassov V, Hu J, Reeves D, van Marwijk H. 2018;33(12):1688-1708. 

19 Moura C, Bernatsky S, Abrahamowicz M, et al. 2014;25(5):1473-81. 

20 Andersen NB, Jørgensen NR. 2022;36(3):101755. 

21 Andersen NB, Jørgensen NR. I 2022;36(3):101755. 

22 Baddoo DR, Mills AA, Kullab RB, et al. 2021;86:29-34. 

23 Meier C, Kraenzlin ME. 2011;3(5):235-43. 

24 Zhong R, Chen Q, Zhang X, et al. 2019;10

25 Fabian CJ. T 2007;61(12):2051-63. 

26 Goldhirsch A, Ingle JN, Gelber RD, et al. 2009;20(8):1319-29. 

27 Chen Z, Maricic M, Pettinger M, et al. 2005;104(7):1520-30. 

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29 Colzani E, Clements M, Johansson AL, et al. 2016;115(11):1400-1407. 

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