# The Potential of Indole Alkaloids in Bone Health and Osteoporosis Management
## 4 Treatment  
The main goal of osteoporosis treatment is to prevent fractures. Some common medication classes are the following:  
Anti-resorptive agents: They inhibit bone loss by reducing osteoclast activity and they include  
* Bishosphonates: These are the most commonly prescribed medications for osteoporosis. They slow bone loss and increase bone density. Examples include alendronate (**1**), ibandronate (**2**), risedronate (**3**), and zoledronic acid (**4**) (Figure 3). * Monoclonal antibodies such as the RANK-L inhibitor (denosumab) and the sclerostin inhibitor (romozumab) [35; 36]. * Parathyroid hormone (PTH) analogs: These medications stimulate new bone formation. Examples include abaloparatide, and teriparatide (teriparatide is a recombinant protein consisting of the first 34 amino acids of the parathyroid hormone). * Selective estrogen receptor modulators (SERMs): These medications mimic some of the effects of estrogen on bone. Raloxifene (**5**) is a common example. * Drugs with dual mechanisms of action (anti-resorptive and anabolic), such as strontium tranelate (**6**). * Calcitonin: This medication slows bone loss but is less commonly used. These treatments are systemic and have a lot of negative effects. Specifically, the most frequent adverse effects linked to bisphosphonates are a fever, gastrointestinal issues, discomfort in the muscles and bones, and necrosis of the jaw. For instance, osteeoncrosis and atypical fractures can be brought on by denosumab and bisphosphonates. However, romosozumab can also result in joint pain and swelling, as well as a heart attack or stroke in those who are more susceptible [37; 38; 39]. After the first year of treatment, 50% of patients elect to discontinue, primarily due to the adverse effects that outweigh the benefits of the medications. This is the reason why a lot of individuals are searching for a medication-free approach to treat the illness. Indole alkaloids may be a potential treatment. The mechanism of action, limitations, and adverse effects of the main drugs used in conventional therapies are shown in Table 1[22; 24; 32; 35; 37; 38; 39]. \begin{table}
\begin{tabular}{c c c c} \hline \hline
**Drugs** & **Mechanism of Action** & **Limitations** & **Adverse Effects** \\ \hline \multirow{8}{*}{Bishosphophonates} & & Highly effective in reducing fracture risk but primarily prevent bone loss rather than building new bone. & Gastrointestinal upset, esophagitis, and in rare cases, bone pain. \\  & & targeting osteoclasts. & Long-term use can lead to medication-related osteonecrosis of the jaw (MRON)) and atypical femoral fractures. & \\ \hline \multirow{8}{*}{Denosumab} & & Effective in reducing fracture risk but similar to bisophosphonates, it primarily prevents bone loss. Long-term safety data are limited. & Increased risk of osteonecrosis of the jaw, atypical femoral fractures, and potentially increased risk of infections. \\ \hline \multirow{4}{*}{Teriparatide} & & Effective in increasing bone mass and reducing fracture risk but its use is limited to two years due to the risk of bone cancer. Expensive. & \\ \hline \multirow{2}{*}{Selective Estrogen Receptor Modulators (SERMs)} & Mimic estrogen’s effects on bone but without affecting the uterus. & Less effective than other options in preventing fractures. & Hot flashes, blood clots, and increased risk of uterine cancer. \\ \hline \multirow{4}{*}{Calcitonin} & & Reduces bone resorption by inhibiting osteoclast activity. & Less effective than other options in preventing fractures. & Nasal irritation (nasal spray), flushing, and increased risk of bone pain. \\ \cline{1-1} \cline{2-5}  & & & \\ \hline \hline \end{tabular}
\end{table} 
Table 1: The mechanism of action, limitations, and adverse effects of the main drugs used in conventional therapies. Figure 3: Structures of bisphosphonates (**1**–**4**); raloxifene (**5**); and strontium ranelate (**6**). Thus, the target of most conventional medications is primarily preventing bone loss rather than stimulating bone formation.