After my own diagnosis, I had to take an honest inventory of everything that might be working against my bones. In my book I call the things that quietly cost you bone "hidden thieves," and some of the most common ones come from the pharmacy.
This post walks through the medications with the best evidence for weakening bone or raising fracture risk. I've written separately about medications that increase your fall risk. That's a different list with some overlap, and both are worth reviewing with your doctor.
First, the most important sentence in this post: please don't stop any medication on your own because of what you read here. Every drug below treats something real, and several of them are lifesaving. Stopping some of them suddenly can be dangerous. The point is to know, so that you and your doctor can protect your bones while you keep getting the treatment you need.
Steroids Like Prednisone
Glucocorticoids, the family of steroid medicines that includes prednisone, are the best-known medication cause of bone loss. They're used for asthma flares, rheumatoid arthritis, lupus, inflammatory bowel disease, and many other conditions.
The American College of Rheumatology's 2022 guideline says that doses of 2.5 milligrams of prednisone a day or more raise the risk of both spine and hip fractures, and even lower doses raise the risk of spine fractures. Bone loss happens fastest in the first three to six months of treatment (American College of Rheumatology, 2022). That's why timing matters.
The guideline recommends a fracture risk assessment for any adult taking 2.5 milligrams or more for longer than three months, ideally within the first six months. It also notes that many people on steroids are never evaluated or treated, which leads to fractures that could have been prevented.
The good news is that protection works. The same guideline found high-certainty evidence that oral bisphosphonates, the most common osteoporosis pills, prevent spine fractures in people taking steroids. If you're on a steroid for months, ask your doctor whether your bones have been checked.
One more thing about steroids. The standard FRAX calculator only asks whether you take them, not how much. My post on FRAX and FRAX-plus explains why that can underestimate risk at higher doses.
Hormone-Blocking Cancer Treatments
Two groups of cancer drugs work by lowering sex hormones, and those same hormones help protect bone.
Aromatase inhibitors are used for many hormone-sensitive breast cancers. They include anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin). They work by lowering estrogen levels even further after menopause. The Arimidex label reports that women in a bone substudy of its major trial lost bone density in both the spine and hip over two years (FDA label for Arimidex).
Androgen deprivation therapy is used for prostate cancer. Drugs like leuprolide (Lupron) lower testosterone dramatically. The Endocrine Society notes that spine bone density typically drops about 3 to 4 percent in the first year, and fracture risk goes up (Endocrine Society guideline, 2012).
These treatments save lives, and nobody should skip them to protect their bones. The American Society of Clinical Oncology recommends that cancer survivors have their fracture risk assessed and get a bone density test if their risk is substantial. When medication is needed, bisphosphonates or denosumab are the preferred options (ASCO guideline, 2019). If you're starting one of these drugs, it's a good time to ask about a baseline DEXA scan.
The Depo-Provera Birth Control Shot
This one may not apply to you, but it may apply to your daughter or granddaughter. Depo-Provera, the birth control injection given every three months, carries the FDA's strongest warning, a boxed warning, for loss of bone density.
In adult women who used it for up to five years, bone density in the spine and hip dropped by an average of 5 to 6 percent. After stopping, bone came back only partway over the next two years. The label says it shouldn't be used for longer than two years unless other birth control methods aren't suitable (FDA label for Depo-Provera). The label notes that bone loss is a particular concern in teenagers and young women, who are still building bone.
Acid Reflux Medicines (PPIs)
Proton pump inhibitors, or PPIs, are some of the most widely used drugs in the country. They include omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid), and pantoprazole (Protonix), and several are sold over the counter.
The FDA label for omeprazole says observational studies have linked PPIs to fractures of the hip, wrist, and spine. The higher risk showed up mainly in people taking them more than once a day, and for a year or longer. The label advises using the lowest dose for the shortest time that treats the condition (FDA label for Prilosec).
"Observational" matters here. These studies can show that two things go together, but they can't prove one causes the other. Still, if you've been taking a PPI for a long time, it's worth asking whether you still need it, or whether a lower dose would work. Make any change with your doctor rather than on your own.
Too Much Thyroid Hormone
Levothyroxine (Synthroid and others) replaces thyroid hormone your body isn't making. The bone concern is getting too much of it. Excess thyroid hormone speeds up bone turnover, so you lose bone faster than you rebuild it.
In a large Canadian study of adults 70 and older, current levothyroxine use was linked with higher fracture risk, and the risk climbed as the dose went up. The authors pointed out that older adults often need less thyroid hormone than they did when they were younger, but doses frequently aren't adjusted (Turner and colleagues, BMJ 2011). This was an observational study, so it shows a link rather than proof.
If you take thyroid hormone, the simple step is to make sure your TSH blood test is checked regularly and your dose is adjusted as you age.
Some Antidepressants
Selective serotonin reuptake inhibitors, or SSRIs, include sertraline (Zoloft), fluoxetine (Prozac), escitalopram (Lexapro), and others. A pooled analysis of 13 observational studies found that people taking SSRIs had about 1.7 times the fracture risk of people who didn't. That number dropped to about 1.4 after the researchers adjusted for the tendency of studies with dramatic results to get published more often (Wu and colleagues, 2012).
It's hard to untangle the drug from the condition it treats, since depression itself can affect falls and bone. And untreated depression causes real harm. I'd never suggest stopping an antidepressant for bone reasons alone. But if you take one and have osteoporosis, your doctor should know about both, and that's one more reason to take fall prevention seriously.
A Few Others Worth Knowing
Pioglitazone (Actos), a diabetes medicine. In a major trial, about 5 in 100 women taking it had a fracture over roughly three years, compared with about 2.5 in 100 women taking a placebo (FDA label for Actos).
Phenytoin (Dilantin) and some other older seizure medicines. The phenytoin label notes that it has been linked to lower bone density and fractures in people with epilepsy (Dilantin prescribing information). If you take a seizure medicine, ask your neurologist whether yours is one that affects bone.
Chapter 6 of my book has a longer table that also covers drugs like long-term heparin and some transplant medicines.
What to Do With This Information
Bring a complete list of everything you take to your next appointment, including over-the-counter medicines and supplements. Then ask two questions:
- Could any of these be affecting my bones?
- For each one, do I still need it, and am I on the lowest dose that works?
Your pharmacist is a great ally here too. Pharmacists see your whole medication list in one place, and they're often the first to spot a problem.
Sometimes the answer will be to lower a dose or switch to a different drug. Often, though, the right answer is to keep taking the medication and add protection for your bones. That might mean a bone density scan, a bone-building or bone-preserving medication, and the everyday basics of exercise, calcium, protein, and fall prevention.
If you've been newly diagnosed, a medication review is one of the steps in my post on what to expect at your first osteoporosis visit. Of all the risk factors for bone loss, your medication list is one of the few you can actually review and sometimes change.