DEAR DR. ROACH: At age 48, I underwent a lumpectomy, chemo and radiation for stage I breast cancer. All is good so far, but I started experiencing osteopenia in my mid-50s, perhaps earlier than I would have because of the chemo and estrogen-blocking meds. My mother also had osteoporosis.
For the osteoporosis in my hip, I took alendronate for five years, but it did not stop the bone loss.
I am now on Prolia, which has helped. I am healthy and fairly active. How long can one take Prolia with breaks in between, and what are your thoughts on alternatives? I am concerned about “running out” of strong, effective alternatives to treat my osteoporosis. I walk 3-5 miles most days.
— A.M.L.
ANSWER: You are right that the estrogen-blocking drugs you needed for your breast cancer caused accelerated bone loss and early osteoporosis. Given your family history and young age, it’s very important to think about the future.
Keeping up your exercise is excellent for your bones, for your overall health, and to reduce your risk of cancer.
Prolia works similarly to alendronate by slowing down the cells that break down bone, called osteoclasts. Unlike alendronate and similar drugs, Prolia stops working as soon as you stop taking it, so people who are on it need to take it continuously.
This is different from alendronate, where people can take “drug holidays” for years sometimes in order to keep the bone from becoming “frozen” and brittle, which can put them at risk for atypical femur fractures.
Between 8% and 10% of people who stop Prolia will get a fracture the following year unless they transition to a different treatment.
Bisphosphonate drugs like alendronate are often the choice for people once they stop Prolia, but they did not work for you. I would be concerned about the absorption of the medicine since taking the medicine with any food can reduce absorption to the point that it isn’t effective.
In addition, you need enough calcium and vitamin D for bisphosphonate drugs (and Prolia) to work properly. But if you are careful about these issues, it may just be that you are one of the people for whom bisphosphonate drugs are not a good option.
Anabolic agents like PTH analogues (teriparitide) would be another good choice since these directly build up bone. Romosozumab both builds bone and decreases breakdown. However, one option that might be a particularly good choice for you is raloxifene, which decreases the risk of breast cancer and helps keep bones strong.
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