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Bone Density and Epilepsy: Are Antiepileptic Drugs a Risk for Osteoporosis?

Posted on April 12, 2022
Medically reviewed by
Ariel D. Teitel, M.D., M.B.A.
Article written by
Ross Phan, PharmD

Osteoporosis is a medical condition in which bones lose density, becoming weak and brittle. This can lead to a higher risk of bone fractures (breaks). People with epilepsy — a range of conditions that cause seizures — are at a higher risk of developing osteoporosis. In fact, people with epilepsy are two to six times more likely to have bone fractures compared with the general public.

Researchers have found a link between long-term antiepileptic drug (AED) use and higher fracture risk. A 2004 study showed that some AED medications can raise fracture risk by as much as 79 percent. AEDs may also lower your bone mineral density (BMD). BMD measures the strength and thickness (density or mass) of your bones.

This article will cover how epilepsy and AEDs can contribute to bone loss, other risk factors for osteoporosis, and ways to keep your bones their strongest.

Falls and Fractures in People with Epilepsy

Epilepsy is linked to a higher risk for osteoporosis and an increased risk of fractures (broken bones). Fractures can have negative effects on the quality of life for people with epilepsy.

One MyEpilepsyTeam member shared, “After my last seizure, I broke my collarbone and eight ribs. I’m petrified every day that if I have a seizure and fall, I could break all over again.”

Osteoporosis also indirectly affects mental health. One member said, “I get pretty depressed that my osteoporosis is so bad. I was a personal trainer, and I used to run six miles a day. Now, I’m petrified to go anywhere for fear of falling and breaking.”

Can Epilepsy Cause Osteoporosis?

Epileptic seizures can lead to falls and fractures, a common fear among people with epilepsy. As such, some people with epilepsy may find themselves less physically active and less likely to engage in weight-bearing exercises — such as weight training or jogging — that help preserve bone density.

People with epilepsy who spend a lot of time indoors may also be at higher risk of developing osteoporosis, due to limited sun exposure which can cause a vitamin D deficiency.

Antiepileptic Drugs and Bone Loss

Some AEDs have been linked to bone abnormalities including bone loss. Following are a few anticonvulsant medications with adverse effects that can contribute to osteoporosis, especially with long-term use.

Phenytoin

Phenytoin — sold as Dilantin — may contribute to bone thinning due to its effects on the liver. It can be administered through an IV or orally as a capsule or liquid. The medication encourages the liver to quickly break down vitamin D and clear the vitamin from your body. Low amounts of vitamin D can also lead to low calcium in the body. If you don’t have enough vitamin D or calcium, you are more likely to have osteoporosis and fractures.

Divalproex Sodium

Divalproex sodium is the bonded form of sodium valproate and valproic acid. The U.S. Food and Drug Administration (FDA) has approved a tablet form of divalproex sodium called Depakote for many uses, including epilepsy, migraine prevention, and the mental health condition bipolar disorder. Despite its versatility, this medication has many side effects, including low BMD. This might be because valproic acid promotes osteoclasts —a type of bone cell that breaks down bone. It may also be linked to low vitamin D.

Carbamazepine

Carbamazepine — sold in liquid and tablet forms as Carbatrol and Tegretol — has a number of possible side effects, including bone loss. Carbamazepine likely causes this side effect because of low vitamin D. It might also encourage bone turnover as well as block the process of making new bone.

This isn’t a complete list of anticonvulsant therapy drugs that may cause bone loss. If you have questions or concerns about the side effects of AEDs, speak with your neurology team. They will help you with the next steps, which may include:

  • Monitoring side effects
  • Recommending vitamin D supplements
  • Changing dosage
  • Switching to another AED

What Are Other Risk Factors for Bone Loss?

Similar to osteoporosis, osteopenia is a medical condition that involves bone loss. Osteopenia is a milder form of low bone mass than osteoporosis. Osteopenia and osteoporosis can affect anyone, but the following factors can increase a person’s risk of developing these conditions.

  • Being 50 or older
  • Being female
  • Being premenopausal
  • Having low body weight
  • Having a family history of osteoporosis
  • Using certain medications such as steroids
  • Drinking more than three alcoholic drinks per day
  • Engaging in minimal exercise

Talk with your health care provider if you have several of these risk factors, or if you have experienced unusual fractures. Your health care provider may recommend a screening for osteoporosis with a bone density scan — also called a dual-energy X-ray absorptiometry scan. This type of scan is used to measure your BMD.

Preventing and Managing Osteoporosis

Following are some ways to prevent osteoporosis — or to manage the condition if it develops. These are general suggestions. They might not apply to all people, depending on factors such as other medical conditions.

Making all of these changes at once can also be overwhelming. Your health care provider can also help you come up with a plan to gradually make these changes.

Eating a Healthy Diet

If you’re not getting enough calcium and vitamin D in your diet, you are at a higher risk of having bone loss. Vitamin D levels can be easily checked with a blood test.

Fortunately, there are plenty of food options that have calcium or vitamin D. Always talk with your health care provider before making any changes to your diet. They will help you make sure that the benefits of the changes outweigh the risks.

The following foods contain calcium:

  • Dark green leafy vegetables, such as kale or bok choy
  • Calcium-fortified products, including certain orange juice or milk products
  • Salmon that’s not deboned

Some examples of foods with vitamin D include:

  • Fortified cereals
  • Egg yolks
  • Fatty fish, including salmon and tuna

Ask your health care provider whether dietary supplements containing calcium and vitamin D might be safe and beneficial for you.

Making Lifestyle Changes

Drinking alcohol and smoking can raise your risk for osteoporosis. To minimize this risk, consider the following:

  • Limit your alcohol intake to one drink per day for women or two drinks per day for men.
  • Avoid exposure to secondhand smoke.
  • Quit smoking.
  • Talk with your health care provider about other ways to lower your risk for osteoporosis.

Staying Physically Active

Physical inactivity is a risk factor for osteoporosis. Regularly exercising can help lower this risk by increasing bone mass and provide the following additional benefits:

  • Strengthening your muscles
  • Improving your balance
  • Maintaining your independence with the ability to perform daily activities

For bone health, consider the following weight-bearing exercises:

  • Walking
  • Jogging
  • Dancing
  • Lifting weights
  • Playing tennis

For better balance, the following may help:

  • Tai chi
  • Yoga-like exercises, such as balancing on one foot
  • Swimming pool exercises

Preventing Falls and Fractures

Osteoporosis increases your risk of fractures. So, preventing falls will also prevent fractures. The following are ways to limit your fall risk:

  • Wearing non-slip shoes
  • Practicing balance exercises
  • Having a well-lit home
  • Using grab-bars in the shower or bathtub
  • Having carpets and rugs that are skid-proof
  • Having handrails on both sides of the stairs
  • Removing clutter and wires in walking areas
  • Limiting medications that increase fall risk — like sleeping pills

Being Screened for Osteoporosis

A bone density scan can detect bone disease and help you start early treatment to prevent fractures. Experts recommend osteoporosis screening for the following:

  • Postmenopausal people
  • Women age of 65 years or older
  • People with multiple risk factors

Treating Osteoporosis

Following are some medication options for treating osteoporosis:

Bisphosphonates

Bisphosphonates are the go-to options for osteoporosis. In general, bisphosphonates work by integrating into the bone and blocking bone breakdown. Alendronate is a common bisphosphonate.

RANKL Inhibitors

RANK and RANKL are types of protein. Prolia — sold as Denosumab — is a RANKL inhibitor that blocks RANKL’s ability to attach with RANK. This is believed to limit the activity of osteoclasts, cells responsible for breaking down bones.

Parathyroid Hormone

Parathyroid hormone (PTH) is a hormone made naturally by the body. Teriparatide — sold as Forteo — is an example of human-made PTH. It works by encouraging bone formation from osteoblasts — bone cells responsible for building bone.

This isn’t a complete list of medications used for osteoporosis. For more detailed information about medications used to treat osteoporosis, talk with your pharmacist or health care provider.

Talk With Others Who Understand

MyEpilepsyTeam is the social network and online support group for people with epilepsy and their loved ones. Here, more than 104,000 members come together to ask questions, offer advice and support, and share stories with others who understand life with epilepsy.

Have you experienced fractures from falls during seizures? Have you been diagnosed with osteoporosis linked to epilepsy or AEDs? Share your experiences and tips in the comments below, or start a conversation on MyEpilepsyTeam.

All updates must be accompanied by text or a picture.
Ariel D. Teitel, M.D., M.B.A. is the clinical associate professor of medicine at the NYU Langone Medical Center in New York. Review provided by VeriMed Healthcare Network. Learn more about him here.
Ross Phan, PharmD is a MyHealthTeam writer with a doctorate in Pharmacy. She is also a founder of Off Script, a pharmacy consulting business. Learn more about her here.

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