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6.4 Disorders of bone metabolism

First line drugs Second line drugs Specialist drugs Secondary care drugs

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

 

6.4 Disorders of bone metabolism      

 

Bisphosphonates   

  

Alendronic acid  

  • Tablets 10mg, 70mg

 

Alendronic acid effervescent (Amber 2)  

  • Binosto® Tablets 70mg

Notes:

  • Reserved for patients who have confirmed swallowing difficulties

 

  • For hospital initiation only in line with local guideline after failure of standard Alendronic acid and risedronate. 

 

 

 

Risedronate

  • Tablets 5mg, 35mg 

NICE TA464: Bisphosphonates for treating osteoporosis (August 2017)

General Notes:

  • Oral bisphosphonates are absorbed very poorly; therefore counselling should be given to the patient as to how and when administration is most appropriate. 
  • Alendronic acid 70mg is a ‘special container' pack of four tablets. These should not be prescribed on weekly prescriptions as the pack can not be split by the pharmacy to provide one tablet.
  • All oral bisphosphonate should be taken in combination with calcium & vitamin D.
  • Alendronic acid, and possibly risedronate, can cause severe oesophageal reactions. Patients should be advised to discontinue treatment and seek medical attention if they develop symptoms of oesophageal irritation, new or worsening heartburn, pain on swallowing or retrosternal pain. Strict guidelines on administration should be followed. 
  • Bisphosphonates are recommened for use in patients with breast cancer
  • MHRA/CHM advice: Bisphosphonates - osteonecrosis of the external auditory canal (December 2015) 

 

 

Sodium Clodronate (TLS: Amber 1)

  • Tablets 520mg, 800mg  

 

Pamidronate disodium

  • Injection 15mg, 30mg, 60mg, 90mg          

Notes:

  • IV disodium pamidronate is licensed to treat hypercalcaemia, osteolytic lesions and bone pain linked to bone/skeletal metastases and that related to Paget’s disease.

 

Zoledronic acid 

  • Injection 5mg/100mL solution for infusion in vial for patients unable to take oral medication for post-menopausal osteoporosis.
  • Zometa® Concentrate for Intravenous Infusion 4mg/5mL for prophylaxis & treatment of Osteolytic lesions and treatment of Hypercalcaemia &  Bone Metastases 

 NICE TA464: Bisphosphonates for treating osteoporosis (August 2017)

 

 

Monoclonal Antibodies

 

Denosumab 

 

Denosumab (Shared care guideline)

  • Subcutaneous injection 60mg per ml 
  • Prolia® Injection 60mg/mL (prefilled syringe) 

Notes:

 

 

 

 

  • Risk of fracture secondary to multiple myeloma if intolerant of or unable to have bisphosphonates

 

 

 

Bone Formation Stimulants

Strontium ranelate (Amber 2)

  • Granules 2g/sachet

Notes:

 

 

Calcitonins 

Calcitonin salmon (Salcatonin) Amber 2 

  • Injection 400 units in 2mL    

Note:

  • Short courses of calcitonin (eg. three times a week for up to 3 months) may be considered for those patients with fragility fractures if alternative analgesics have been unsuccessful.

 

  • In Haemato Oncology it is used to correct hypercalcaemia linked to the following :

               Highest in patients with multiple myeloma and breast cancer

               Intermediate in patients with non-small cell lung cancer and lymphoma

               Rare in patients with renal cell, colon, and small cell lung cancer

When: For hypercalcemia greater than or equal to 4 mmol/L

Dose: IM/SC Calcitonin: 4-8 unit/kg every 6h x 2 days 

 

Parathyroid hormone

Teriparatide

  • Subcutaneous injection 250 micrograms/ml 

Notes:

Use as per NICE TA161: Raloxifene and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women (Oct 2008; Last updated Feb 2018)

 

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

 

 

 

 

Return to Chapter: 6. Endocrine System

Last updated by: Dupe Fagbenro on 13-09-2018 16:16