Bone protection treatment
Medicines that strengthen bone and lower the chance of breaking a bone (fracture) in people with osteoporosis or a high fracture risk; their benefit depends heavily on taking them as directed.
✓ Medically reviewed by a GMC-registered consultant · last reviewed September 2026 · next review September 2027 · how we review
In short
- Bone protection medicines strengthen bone and lower the risk of fractures, especially of the hip, spine and wrist.
- You will not feel them working — the benefit is in fractures that are prevented, which builds over months and years.
- Taking them correctly and consistently is essential; the most common reason they fail is not being taken as directed.
- Serious side effects are rare, treatment is usually reviewed after a few years, and your clinician weighs the benefits and risks for you.
A plain-English summary. The detail — including risks and recovery — is below.
At a glance
A general guide. Your specialist will give you advice for your situation.
Reduces the risk of fractures, particularly of the hip, spine and wrist
Oral bisphosphonates may not suit people who cannot sit or stand upright for the required time, or who have certain gullet problems.
You begin tablets, an injection or an infusion. With infusions, flu-like symptoms can occur for a day or two, usually after the first dose, and are eased...
Clear, written instructions on how and when to take the medicine, and why consistency matters.
You begin tablets, an injection or an infusion. With infusions, flu-like symptoms can occur for a day or two...
You settle into the routine — especially the upright, empty-stomach rule for tablets. Calcium and vitamin D are...
There is nothing to feel, because the benefit is in fractures prevented. Any stomach upset with tablets, or how an...
Bone density may be rechecked and progress reviewed. Treatment continues as long as the benefit holds.
What is bone protection treatment?
Bone protection treatment means medicines that strengthen bone and reduce the chance of breaking a bone. It is used for people who have osteoporosis (thinned, weakened bone) or who are at high risk of fragility fractures — breaks that happen from a minor knock or fall that would not normally break a healthy bone.
The most common medicines are bisphosphonates, such as alendronate or risedronate taken by mouth, or zoledronic acid given as a yearly drip. Others, such as denosumab, are given by injection. They work mainly by slowing down the natural breakdown of bone, helping it stay stronger.
The purpose is fracture prevention — especially of the hip, spine and wrist — which in older people can mean avoiding serious loss of independence. The treatment does not make bones feel any different day to day, and you will not notice it working; its benefit is in the fractures that do not happen.
Because the benefit builds quietly over time, taking the medicine as directed matters enormously. A medicine left in the cupboard cannot protect your bones, so getting the routine right, and sticking with it, is central to the whole treatment.
Types, options & approaches
There may be different ways to do this. The right approach depends on the clinical question and your circumstances.
Tablets versus injection or infusion
| Oral tablets | Injection or infusion |
|---|---|
| Taken at home, weekly or monthly | Given by a nurse, twice yearly or yearly |
| Strict routine: empty stomach, upright | No daily routine to remember |
| Can irritate the gullet or stomach | Flu-like symptoms can follow infusion |
| Easy to start and stop | Some (denosumab) must not be stopped abruptly |
The best choice depends on your other conditions, how well you absorb tablets, and how easily you can keep to a routine. Your clinician will help you decide.
Preparing for your treatment
- Have your fracture risk assessed properly — usually with a risk calculator (such as FRAX or QFracture) and often a DEXA bone density scan — so treatment is based on your overall risk rather than on age or one scan alone.
- Tell your clinician about swallowing problems, heartburn or stomach ulcers, kidney problems, and any planned dental work.
- Have a dental check and any needed dental work before starting, as this lowers an already small risk of jaw problems.
- List all your medicines and supplements, including calcium and vitamin D.
- Ask how to take the medicine correctly — timing, water, staying upright — as this strongly affects whether it works.
- Discuss how long treatment is likely to last and when it will be reviewed.
- Make sure your calcium intake and vitamin D level are adequate before and during treatment.
What happens
First, your fracture risk is assessed — usually with a risk calculator such as FRAX or QFracture and often a DEXA scan that measures bone density. Current UK guidance suggests considering a fracture-risk assessment for people aged 50 and over who have risk factors, for postmenopausal women with risk factors, and more routinely for women aged 65 and over and men aged 75 and over. In some people the DEXA scan is also used to look for small, often painless spinal (vertebral) fractures that change the picture of risk. Whether to treat is then decided together with you, based on your overall fracture risk, your bone density and any previous fractures — rather than on a single universal cut-off.
For tablets, you are shown exactly how to take them: typically on an empty stomach, first thing, with a full glass of plain water, staying upright and not eating for a set time afterwards. This protects the gullet and helps the medicine absorb.
For an infusion, you attend as an outpatient and the medicine is given through a drip over a short time. For denosumab, a nurse gives an injection under the skin, usually every six months.
Throughout, calcium and vitamin D are checked and topped up if needed. Your clinician explains the benefits and the small risks, agrees how long you will take it, and arranges review — including a planned point, often after several years, to decide whether to continue, pause or change.
Is this treatment right for me?
A good consultation should explore whether it's the right choice for you now — including reasons to wait or consider something else.
May not be suitable if…
- Oral bisphosphonates may not suit people who cannot sit or stand upright for the required time, or who have certain gullet problems.
- They are generally avoided in significant kidney impairment and in untreated low calcium, which must be corrected first.
- Treatment is not started purely on age or a single low scan without proper fracture-risk assessment.
- Denosumab is not suitable for someone who cannot commit to regular, uninterrupted dosing or follow-on treatment.
Delay or rearrange if…
- Calcium is low or vitamin D is deficient — correct these first.
- There is significant unaddressed dental disease or planned major dental surgery — a dental check is advisable first.
- Kidney function is too low for the chosen medicine, pending review.
- The person is pregnant or breastfeeding, or planning pregnancy, in which case specialist advice is needed.
Alternatives to discuss
- Lifestyle measures alone — adequate calcium and vitamin D, weight-bearing exercise, stopping smoking, limiting alcohol — where risk is lower.
- A different bone protection medicine if one is not tolerated.
- An infusion or injection instead of tablets if absorption or routine is a problem.
- Bone-building (anabolic) treatment for severe osteoporosis under a specialist.
- Watchful monitoring with falls prevention where fracture risk is borderline.
Before you decide
Use this as a shared-decision checklist. The aim is not just “can this be done?”, but whether it is right for you, now, with the risks and alternatives clearly understood.
What matters most to me?
Think about symptoms, daily life, work, caring responsibilities, sport, fertility, travel, appearance and anxiety — the right choice depends on your priorities, not just the medical facts.
What are all my options?
Ask about waiting, monitoring, medicines, rehabilitation, a smaller or larger procedure, a different test, NHS referral, or a second opinion where that would help.
What would make me pause?
Active infection, pregnancy, unstable medical problems, smoking, medicines that increase bleeding, poor support at home, or feeling pressured are all reasons to slow down and get tailored advice.
What happens if I do nothing today?
For some problems, waiting is safe; for others, delay can make treatment harder. A good consultation should explain the trade-off in plain English.
Benefits
- Reduces the risk of fractures, particularly of the hip, spine and wrist
- Can help prevent the serious loss of independence that a hip or spine fracture may cause
- Slows the bone loss that comes with osteoporosis and ageing
- Several options, including yearly or twice-yearly injections, to suit different people
- Backed by good evidence for fracture prevention in those at high risk
- Treatment can be reviewed and adjusted over time rather than continuing indefinitely
Risks & complications
- Stomach upset, heartburn or irritation of the gullet with oral tablets
- Flu-like aches, fever or tiredness for a day or two after an infusion (usually with the first dose)
- Low calcium can occur, so calcium and vitamin D are checked and topped up
- Muscle, bone or joint aches
- Injection-site reactions or, with denosumab, occasional skin or infection problems
- Difficulty taking tablets correctly, which reduces their benefit
- Osteonecrosis of the jaw — a problem with healing of the jaw bone, usually linked to dental procedures and long treatment
- Atypical femoral fracture — an unusual thigh-bone fracture, with risk rising after several years of treatment; new thigh or groin pain should be reported
- Severe allergic reactions
For most people at high fracture risk, the benefit of preventing fractures clearly outweighs the small risks. The two most talked-about rare risks — osteonecrosis of the jaw and atypical thigh-bone fractures — are uncommon and tend to relate to longer treatment, which is exactly why treatment is reviewed after a few years and a 'drug holiday' is sometimes considered. The most important practical point is the opposite of a side effect: these medicines only protect you if taken as directed. Report new thigh, hip or groin pain, or jaw pain or dental problems, and keep up dental care.
Published figures to discuss
For people at genuinely high fracture risk, bone protection reduces fractures and the benefit generally outweighs the small risks. The rare risks below relate mainly to longer treatment, which is why treatment is reviewed periodically. Figures are drawn from published estimates and vary by drug, dose, duration and individual; they should be discussed in the context of your own fracture risk.
| Figure | Reported range | How to interpret it | Source / confidence |
|---|---|---|---|
| Osteonecrosis of the jaw | Very rare at osteoporosis doses — estimated around 1 in 1,000 to 1 in 100,000 person-years in various reports | Risk rises with longer treatment and is linked to dental procedures; a dental check before starting and good dental care lower it. Much higher rates relate to high cancer doses, not osteoporosis treatment. | NICE NG259 — Fragility fracture risk assessmentnice.org.ukPublished figure |
| Atypical femoral (thigh-bone) fracture | Rare; risk increases with duration, roughly from around 2–3 per 10,000 person-years at up to 5 years to higher with longer use | New thigh, hip or groin pain should be reported. The absolute risk stays low and is far outweighed by the fractures prevented in high-risk people. | NICE NG259 — Fragility fracture risk assessmentnice.org.ukPublished figure |
| Flu-like reaction after intravenous bisphosphonate | Common after the first infusion; much less likely with later doses | Usually short-lived; fluids and simple painkillers, if advised, help. It does not mean an allergy. | Guide sourcesClinical context |
These are literature figures, not a personalised prediction. Your own risks and likely benefits depend on your circumstances, your health, and how your care is carried out and followed up.
What happens afterwards
There is no recovery in the surgical sense. "Afterwards" is about taking the treatment correctly over time, watching for the few things that matter, and keeping to the planned reviews.
- Feeling no different — the medicine works silently in the background
- Mild stomach symptoms with tablets, or short-lived flu-like aches after an infusion
- Getting used to the tablet-taking routine in the first few weeks
- Periodic blood tests and bone density scans as part of monitoring
Aftercare
- Take the medicine exactly as directed — for tablets, on an empty stomach with plain water, staying upright and not eating for the advised time.
- Keep taking it consistently; the benefit depends on adherence, and a missed routine reduces protection.
- Maintain enough calcium and vitamin D, through diet or supplements as advised.
- Keep up dental care and tell your dentist you are on bone protection treatment.
- Report new thigh, hip or groin pain, or jaw pain, swelling or non-healing after dental work.
- Do not stop denosumab without arranging follow-on treatment, as stopping abruptly can cause rapid bone loss.
- Attend reviews and blood tests, and discuss any side effects rather than just stopping.
- Fracture risk assessed (FRAX or QFracture, and/or DEXA scan)
- Dental check and any needed work done before starting
- Clear instructions on exactly how to take the medicine
- Calcium and vitamin D intake or levels checked
- A plan for how long treatment will last and when it is reviewed
- Knowledge of which symptoms to report
- A reminder system to help take the medicine consistently
⚠ Get urgent help if…
- New or worsening pain in the thigh, hip or groin — this can rarely warn of an atypical thigh-bone fracture, so report it
- Jaw pain, swelling, loosening teeth or an area in the mouth that will not heal, especially after dental work
- Symptoms of low calcium — numbness or tingling around the mouth or in the fingers, or muscle cramps or spasms
- Severe heartburn, chest pain on swallowing, or difficulty or pain swallowing with oral tablets
- Signs of a severe allergic reaction — rash, swelling of the face or throat, or breathing difficulty (call 999)
- A new fracture from a minor injury despite treatment
- Severe or persistent flu-like symptoms after an infusion that do not settle
Who to contact: your clinician, clinic or test provider first (keep their number to hand). For urgent advice when you can't reach them, call NHS 111. In an emergency, call 999.
General guidance — it doesn't replace the specific advice your specialist gives you.
Results & realistic expectations
A good outcome is fewer fractures over time and stable or improved bone density, with the medicine well tolerated. Because you cannot feel bones being protected, success is judged over years — by fractures that do not happen and by monitoring such as DEXA scans — rather than by any day-to-day change.
Treatment reduces fracture risk but does not abolish it: fractures can still occur, and the medicine cannot reverse osteoporosis completely or guarantee you will never break a bone. Its job is to tip the odds meaningfully in your favour, which it does best when taken consistently and reviewed sensibly.
Bone protection is usually a long-term treatment, but not necessarily lifelong. Oral bisphosphonates are often reviewed after about five years (three years for a yearly infusion), when a 'drug holiday' may be considered for lower-risk people, because protection can persist for a time after stopping and this lowers the small risks of long-term use. Higher-risk people may continue longer. Denosumab is different — its effect wears off quickly, so it should not simply be stopped without follow-on treatment.
Related tests, treatments or support
Bone protection treatment is usually combined with adequate calcium and vitamin D, and with measures to reduce falls, such as a falls assessment, a postural blood pressure check and a medication review. It often follows a comprehensive geriatric assessment and may be started after a fragility fracture as part of preventing the next one.
Follow-up & long-term care
Follow-up includes checking how well the medicine is tolerated and taken, blood tests for calcium and kidney function where relevant, and periodic bone density scans. Your clinician sets a planned review — often after a few years — to decide whether to continue, pause or change treatment, and reviews sooner if there are side effects or a new fracture.
- Take the medicine consistently and correctly for as long as advised
- Keep calcium and vitamin D adequate
- Maintain dental care and inform your dentist of the treatment
- Attend planned reviews and bone density scans
- Reassess treatment at the planned review point (often after 3–5 years)
- Keep reducing falls risk alongside the medicine
Repeat, follow-on and what comes next
- Treatment is reviewed after a planned period (often around 5 years for tablets, 3 for a yearly infusion) to decide whether to continue, pause or switch.
- A 'drug holiday' may be considered for lower-risk people, as some protection persists after stopping bisphosphonates.
- Denosumab must not simply be stopped — follow-on treatment is needed to prevent rebound bone loss.
- Treatment may be changed if it is not tolerated or if fractures occur despite it.
Ask what happens if the result is unclear or needs repeating, and what is included if further tests or follow-up are needed.
What good aftercare looks like
- Clear, written instructions on how and when to take the medicine, and why consistency matters.
- Checks of calcium and vitamin D, and kidney function where relevant.
- Advice to keep up dental care and to report thigh, hip, groin or jaw symptoms.
- A planned review point to decide on continuing, pausing or changing treatment.
- Falls-prevention support alongside the medicine, and a named contact for questions or side effects.
What affects the cost
Costs vary a great deal between people and providers, and we don't publish prices. What matters is understanding what drives the cost and making sure your quote is complete. The main things that affect it:
- Whether the assessment includes a DEXA bone density scan and a fracture risk calculation
- The type of medicine — tablets, an injection or an infusion
- Whether infusions are given in an outpatient or day-unit setting
- Blood tests for calcium, vitamin D and kidney function
- Any dental assessment recommended before starting
- Follow-up appointments and repeat bone density scans over time
- The cost of the assessment, including any DEXA scan and risk calculation
- The medicine itself and how it is given
- Any facility fee for an infusion or injection visit
- Blood tests and monitoring included or charged separately
- Follow-up appointments and repeat scans
- What happens, and any cost, if the medicine is not tolerated and needs changing
- The cancellation policy
On the NHS? Bone protection medicines are widely available on the NHS when fracture risk justifies treatment, and also privately; the medicines and how they are taken are the same.
You're entitled to your total cost in writing — including reports, follow-up and what happens if the result is inconclusive — before you decide.
Consent traps and marketing red flags
These are not small details. They are often where patients lose choice, time to reflect, or realistic expectations.
Consent traps
- Not assessing fracture risk properly before starting treatment.
- Failing to explain how to take oral tablets, so they do not work and the gullet is at risk.
- Overstating the rare jaw and thigh-bone risks so people stop a medicine that is protecting them.
- Not arranging a dental check or warning about reporting thigh, hip, groin or jaw pain.
- Stopping denosumab without follow-on treatment, risking rebound fractures.
Marketing red flags
- Promising to 'reverse osteoporosis' or guarantee you will never break a bone.
- Starting treatment from a single scan without proper risk assessment.
- Downplaying the importance of taking the medicine correctly and consistently.
- Selling supplements or scans as a substitute for assessed, evidence-based treatment.
Choosing a specialist safely
- Check the specialist is on the GMC Specialist Register for this area.
- Make sure they work at a CQC-registered service, and look for membership of the relevant Royal College or professional body.
- You're entitled to time to consider and to have your questions answered before you agree — the specialist who looks after you should explain it, not a salesperson.
- Be wary of pressure: time-limited offers or deposits taken before you've had time to think are red flags, not bargains.
- You're entitled to your total cost in writing — including any follow-up — before you decide.
Questions to ask your medical professional
Take this to your consultation. A good specialist will welcome every one of these.
- What is my fracture risk, and how much would treatment reduce it for me?
- Which medicine suits me best — tablets, an infusion or an injection — and why?
- Exactly how and when should I take it for it to work?
- How long will I be on it, and when will we review whether to continue, pause or change?
- What side effects should I watch for, and what should I report straight away?
- Do I need a dental check first, and how do I look after my bones with diet and falls prevention?
- Are you on the GMC Specialist Register for this area, and which Royal College or professional body are you a member of?
- Will you be the specialist who carries out my treatment, and who looks after me afterwards?
- What are the risks for someone like me, and how often do your own patients have a problem or need it repeated or redone?
- What does a realistic result look like — and what can this treatment not achieve?
- What are my options, including waiting, doing nothing for now, or choosing a different approach?
- Can I have written information, results and aftercare instructions in a format I can use, including any accessibility or communication support I need?
- What is the total cost in writing, including any follow-ups, and how much time do I have to decide?
Frequently asked questions
Will I feel any different on bone protection treatment?
Why do I have to take the tablets in such a particular way?
I have heard about jaw and thigh-bone problems — should I be worried?
How long will I be on treatment?
Can I just stop if I feel fine or have side effects?
Is this available on the NHS?
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How we made this page
Medically reviewed by a GMC-registered consultant. Written in plain English, checked against NHS, NICE, GMC and relevant Royal College / specialist-society guidance, and kept under review. No clinic paid to appear on this page, and we publish no pricing. This is general information to help you prepare — it is not a substitute for advice from your own clinician. How we review our guides →
Source hierarchy: UK regulator and NHS/NICE guidance first, then relevant Royal College or specialist-society guidance, then peer-reviewed evidence for procedure-specific figures where available.
Sources & standards: Royal Osteoporosis Society — Drug treatments NICE TA464 — Bisphosphonates for treating osteoporosis NICE NG259 — Fragility fracture risk assessment NHS — Osteoporosis treatment FRAX — Fracture Risk Assessment Tool (University of Sheffield) NICE NG259 — Identifying vertebral fragility fractures NICE NG259 — Deciding whether pharmacological treatment is appropriate
Reviews reflect patients' experience of care, not clinical outcomes. For procedure volumes and outcome data see PHIN.
Last medically reviewed 2026-09-21. Spotted something wrong or out of date? Report an error in this guide.
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