Epilepsy medicines and problems with bone health

What is osteoporosis?

Osteoporosis is a condition that weakens bones, making them more likely to fracture (break).

Osteopenia is the stage before osteoporosis. Osteopenia does not always progress to osteoporosis.

How do epilepsy medicines affect bones?

Some epilepsy medicines may make bones weaker and increase the risk of osteoporosis if you take them over a long time. These medicines include:

• Carbamazepine
• Phenobarbital
• Phenytoin
• Primidone
• Sodium valproate

There are clearer links between osteoporosis and older epilepsy medicines, compared to newer ones.

There is less evidence about how newer epilepsy medicines affect bone health. Lamotrigine, levetiracetam, and lacosamide may be safer for bones. But the evidence is not conclusive and more research is needed.

Some studies suggest that topiramate may make bones weaker. But again, more research is needed.

It might be worrying to read about possible side effects. But do not stop taking your epilepsy medicines because this could cause you to have more seizures. Talk to your epilepsy specialist, specialist nurse or GP about any concerns that you have.

Epilepsy Action has more information about epilepsy medicines.

What causes osteoporosis?

Osteoporosis is caused by a loss of bone mineral density (BMD). This happens to most of us as we get older.

Bone mineral density is used to describe the mineral content in your bones. It is an indicator of bone strength.

Some epilepsy medicines may cause a reduction in bone mineral density. Researchers are still trying to find out exactly how epilepsy medicines cause this. Some medicines may affect how we process hormones and vitamin D. Others might affect the biology of the bone itself.

Osteoporosis affects women more than men. 1 in 2 women over 50 will fracture a bone because of osteoporosis, compared to 1 in 5 men. You are more likely to develop osteoporosis if you have been through menopause.

Am I at risk of having osteoporosis?

As well as taking epilepsy medicine for a long time, other risk factors can include:

• Having low vitamin D levels. Vitamin D is important for bone health. Our levels of vitamin D can become low if we don’t spend enough time in sunlight
• Taking certain medicines, such as high-dose steroids or medicines that affect hormone levels. For example, some breast or prostate cancer treatments
• Having a family history of osteoporosis, particularly a hip fracture in a parent
• Being a heavy drinker or smoker
• Not having enough calcium in your diet
• Not exercising regularly or moving around for very long periods of time (being immobile). For example, long-term bed rest
• Having low body weight
• Going through menopause or having a hysterectomy before the age of 45
• Having or had an eating disorder like anorexia or bulimia
• Overactive or underactive thyroid (hyperthyroidism or hypothyroidism)

You cannot control everything on this list. But there are some positive steps you can take to reduce your risk of problems with bone health.

How can I reduce my risk of osteoporosis?

• NICE (National Institute for Health and Care Excellence) recommends taking vitamin D and calcium supplements if you are taking epilepsy medicines linked to bone issues. Studies have shown that vitamin D has positive effects on bone health in people with epilepsy who have low levels of vitamin D in their bodies
• Exercise regularly
• Eat a balanced diet rich in calcium and vitamin D (dairy, leafy greens, fish, eggs)
• Consider HRT if you are going through or have been through menopause. Discuss this with your healthcare professional
• Stop smoking and reduce alcohol consumption
• Talk to your healthcare professional about how other conditions may affect your bone health

Can I check my osteoporosis risk?

The Royal Osteoporosis Society have an online tool to understand your own risk factors for osteoporosis. Visit their website to find out more about your own risk.

This tool is for people who haven’t seen a doctor about their bone health yet, not for those already diagnosed with osteoporosis.

How is osteoporosis diagnosed?

You can talk to your doctor or nurse about your risk of developing osteoporosis.

They will look at your risk factors, including your age, sex, health, medications and lifestyle. They can then assess your ‘fragility fracture risk’. This is your risk of breaking a bone in the future. It will take into consideration your different risk factors.

They may refer you for a scan to measure your bone strength. This is called a bone density (DEXA) scan. It is a short, non-invasive, painless procedure.

You may find out that you have ‘osteopenia’. This means that your bone density is lower than expected, but not low enough to be diagnosed as osteoporosis.

You can request a review with your epilepsy specialist if you have concerns about your bone health or if your condition changes.

How is osteoporosis managed and treated?

• Talk to your doctor or nurse. They might recommend that you take vitamin D. You may need to take a calcium supplement if you are unable to get 750mg of calcium a day in your daily diet. This increases to 1000mg calcium if you have osteoporosis. They may also be able to prescribe certain medicines to treat osteoporosis, for example bisphosphonates
• Stay active and exercise regularly. Weight bearing exercise can help to keep your bones strong. This is exercise where you are standing, like walking or dancing. The Royal Osteoporosis Society have several fact sheets and videos to help you exercise safely
• Eat a healthy, balanced diet. Include foods that are high in calcium and vitamin D like dairy products, leafy green vegetables, fish and eggs
• Hormone replacement therapy (HRT) may be an option if you have been through menopause. HRT has been shown to be beneficial for bone health. Find out more about HRT by visiting our HRT webpage and speaking to your healthcare professional

More research is needed to know what treatments might help people with osteoporosis specifically caused by taking epilepsy medicines. The NHS website has more information about treating osteoporosis in general.

The Royal Osteoporosis Society’s free BoneMed Online service may be helpful if you have been prescribed an osteoporosis medicine. It gives information, tips and videos tailored to you based on the osteoporosis medicine that you are taking. Find out more about the online service.

Staying safe with epilepsy

You might need to take extra steps to keep your bones as safe as possible if you have osteoporosis during seizures or falls. We have more information about safety and first aid.

Further support

The Royal Osteoporosis Society has information on prevention and treatment, local support groups and a helpline. You can also watch their introduction video ‘What is osteoporosis?’

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