How to Build Super Bones
There is a little-known but extremely powerful agent with the potential to dramatically improve bone density (and thus vastly reduce fracture risk) in everyone: teriparatide.
Teriparatide is a synthetic analog of parathyroid hormone (PTH), which is produced by the parathyroid glands and plays a central role in regulating plasma calcium levels and bone metabolism. Chronically elevated PTH levels are catabolic to bone, but intermittent elevations (such as those achieved with once-daily dosing) have strong osteoanabolic (bone building) effects. In fact, PTH analogs are currently the most potent bone-building agents available. They work by upregulating osteoblast activity more than osteoclast activity and therefore speed up bone remodeling.
Because bone mass progressively declines with age (often culminating in fractures that lead to inactivity, sarcopenia, and loss of independence) it makes sense to proactively increase bone mass using teriparatide at least once later in life (for example, around age 50).
With very few exceptions, virtually all women should be on hormone replacement therapy after menopause (topic for another day). However, HRT alone is often insufficient to fully address age-related bone loss.
As people age, they lose height and develop spinal microfractures, which contribute to chronic back pain and functional impairment. More dramatically, femoral neck fractures (far from rare) are associated with a 500–1000% increase in all-cause mortality during the first year, especially in frail individuals with comorbidities. Mortality often remains nearly doubled for the remainder of life. Statistically, one in three women and one in five men will sustain a hip fracture after age 50. Even non-femoral hip fractures, while less severe, are still associated with a 40–50% increase in mortality over five years.
Beyond mortality, fractures cause permanent reductions in mobility. Older adults frequently struggle to regain muscle mass after periods of enforced inactivity, leading to lasting impairments in quality of life: fewer walks, reduced social interaction, diminished ability to exercise, and cascading secondary and tertiary health consequences.
I previously worked with a university osteologist and asked him what he would personally do if he developed osteoporosis. His answer was straightforward:
Use teriparatide for two years.
Follow with a single infusion of zoledronic acid (or a short course of oral alendronate) after discontinuation.
The exact same strategy can be used to skyrocket peak bone mass with pretty much zero risks or downsides (other than daily injections and financial expenses).
The rationale is that after stopping teriparatide, bone enters a transient state of increased remodeling, which can lead to a few months of accelerated bone loss. This loss is modest and does not negate the gains achieved, but bisphosphonates effectively blunt this post-treatment remodeling phase and help preserve the newly built bone.
In my view, this strategy should not be limited to people who already have osteoporosis. It can, and arguably should, be applied preventively to everyone after age 50–55. If this were done at a population level, fracture rates would almost certainly drop substantially.
I know several people who have used teriparatide myself included (in my case, to accelerate recovery after labral surgery). Aside from some transient lethargy after injection early on (which can be avoided by dosing at night) none experienced meaningful side effects.
What about risks? There is a very small increase in osteosarcoma risk, but it is nearly negligible. The Forteo Patient Registry followed approximately 100,000 patients and identified only five confirmed cases of osteosarcoma, a rate only slightly higher than background incidence (roughly 3–4 cases per million in the general population).
Teriparatide is synergistic with weight-bearing activity in the same way anabolic steroids are synergistic with resistance training. With access to the drug, this approach offers a way to achieve a durable increase in bone mass that can persist for decades.
Finally, there is preliminary evidence suggesting that teriparatide may also have chondroregenerative effects, particularly in peri-injury contexts, indicating potential modest benefits for cartilage tissue as well.
In the EU a single pen (lasting for a month) costs about 200 Euros, in the US, unfortunately, a couple of thousand $.