Table 1.

Commonly prescribed medications that have harmful effects on bone homeostasis leading to decreases in bone mineral density and increases in fractures.

Drug class	Mechanism of action	Reversibility on medication discontinuation	Screening recommendation	Management recommendation	Alternate medication
Glucocorticoids (GC)	Decreased bone formation and increased bone resorption	Fracture risk decreases to baseline within 2 years	Fracture risk analysis with DXA or FRAX Monitor vitamin D and calcium levels	Calcium and vitamin D supplementation Bisphosphonate or teriparatide according to fracture risk DXA scan every 2 years	Limit dose and duration of GC Use alternative immunosuppressive agents according to underling disease condition
Proton pump inhibitors (PPIs)	Unknown but maybe due to decreased intestinal absorption of calcium	Fracture risk reverses within 1 year	No recommendation	Calcium and vitamin D supplementationIf possible, avoid PPI use with bisphosphonates	H2 blockers
Antiepileptic drugs (AEDS)	Uncertain but may include inactivation of vitamin D	Unknown	Fracture risk analysis with DXA or FRAX Monitor vitamin D and calcium levels every 6–12 months	Calcium and increased vitamin D supplementation:nonenzyme-inducing AEDs give 1000–1200 IU vitamin D and for enzyme-inducing AEDs give 2000-4000 IU vitamin D daily Bisphosphonates in postmenopausal women and men >50 years	Newer agents like levetiracetam
Medroxyprogesterone acetate (MPA)	Reduced estrogen level leading to increased bone resorption	Partial to full recovery of bone loss at spine and hip	DXA scan controversial in this premenopausal population Monitor vitamin D and calcium levels	Calcium and vitamin D supplementation Limit therapy to 2–3 years No data on bisphosphonates prophylaxis and is currently not recommended	Oral hormonal contraceptives, low-dose estrogen replacement with depot MPA, other birth control methods
Aromatase Inhibitors	Reduced estrogen production leading to increased bone resorption	Unknown	Fracture risk analysis with DXA or FRAX Monitor vitamin D and calcium levels	Calcium and vitamin D supplementation Bisphosphonates for moderate- to high-risk patients Denosumab as alternative DXA scan every 2 years while on treatment	Not applicable
GnRH agonists	Prevent the production of LH and FSH thereby decreasing testosterone and estradiol leading to increased bone resorption	May be reversed in 2 years depending on dose and duration of therapy	Fracture risk analysis with DXA or FRAX Monitor vitamin D and calcium levels	Bisphosphonates, denosumab,raloxifene, or toremifene for moderate- to high-risk patents DXA scan every 2 years while on treatment	Second line: androgen receptor blockers in men without bone metastasis
Serotonin selective reuptake inhibitors	Uncertain	Probable	Fracture risk analysis with DXA or FRAX for patients with other osteoporosis risk factors Monitor vitamin D and calcium levels	Calcium and vitamin D supplementation	Alternative classes of antidepressants
Thiazolidinediones	Decreased bone formation	Unknown	Fracture risk analysis with DXA or FRAX for patients with other osteoporosis risk factors Monitor vitamin D and calcium levels	Avoid in established osteoporosis No data for prevention	Metformin, sulfonylureas, insulin
Calcineurininhibitors	Excessive osteoclasts and bone resorption with glucocorticoids	Unknown	DXA/FRAX analysis prior to kidney transplant Monitor vitamin D and calcium levels	Calcium and vitamin D supplementation DXA prior to and every 2 years post organ transplant Bisphosphonates for T score < −2.0
Heparin	Osteoblast inhibition with decreased bone formation; increased bone resorption	Near complete reversal of BMD	No published recommendations	No published recommendations	Fondaparinux if applicable
Warfarin	Decreases bone mineralization	Unknown	No published recommendations	No published recommendations

BMD, bone mineral density; DXA, dual energy X-ray absorptiometry; FSH, follicle-stimulating hormone; GnRH, gonadotropin-releasing hormone agonist; LH, luteinizing hormone.