NICE have produced guidance on how to administer pharmacological treatments for Osteoporosis. This guidance is divided into two sections: Primary and secondary prevention of fractures.
For more information on primary prevention visit:
www.nice.org.uk/guidance/ta160/resources/guidance-alendronate-etidronate-risedronate-raloxifene-and-strontium-ranelate-for-the-primary-prevention-of-osteoporotic-fragility-fractures-in-postmenopausal-women-amended-pdf
For more information on secondary prevention of fractures visit:
www.nice.org.uk/guidance/ta161/resources/guidance-alendronate-etidronate-risedronate-raloxifene-strontium-ranelate-and-teriparatide-for-thesecondary-prevention-of-osteoporotic-fragility-fractures-in-postmenopausal-women-amended-pdf
The NHS website provides an excellent explanation of the drug treatments available. For more information visit:
www.nhs.uk/conditions/osteoporosis/pages/treatment.aspx
The National Osteoporosis Society provide a comprehensive review of all the drug treatments available. For more information visit:
www.nos.org.uk/scans-tests-drugs/drug-treatments
They also produce a leaflet for patients on osteoporosis treatments:
National osteoporosis Society patient information leaflet.
Calcium & Vitamin D
In patients with osteoporosis it is essential that there is adequate Calcium and Vitamin D intake. Wherever there is doubt then supplements should be prescribed. Usually supplements will contain both calcium and vitamin D but there are now oral supplements of pure vitamin D available.
Bisphosphonates
E.g. Alendronate, Risedronate, Zolendroic Acid
Bisphosphonates work by deactivating osteoclasts. They are often prescribed in conjunction with Calcium and Vitamin D supplementation, and tend to take 6-12 months to start having an effect. Oral bisphosphonates should only be given to patients who are able to remain upright after taking them and who do not have difficulty swallowing or significant reflux symptoms. They are contraindicated in patients with an eGFR <35 and should be discontinued in any patient who develops upper GI side effects. If gastrointestinal side effects are experienced on alendronate then risedronate should be trialed. In patients unable to take oral bisphosphonates then referral to secondary care to consider intravenous zoledronate may be appropriate.
Denosumab
Denosumab is a monoclonal antibody that inhibits osteoclasts through binding to RANK ligand. It is given by subcutaneous injection six monthly. The first injection is given in secondary care after which responsibility for subsequent injections is handed over to primary care. Patients must be calcium and vitamin D replete prior to treatment and caution is needed in renal impairment due to the increased risk of inducing hypocalcaemia.
Teriparitide
It is given as an injection and at present it is available to a small number of patients who have very severe osteoporosis and who don’t respond to other treatment. Parathyroid hormone can only be prescribed by an osteoporosis specialist. Side effects include nausea and vomiting.
Strontium
Strontium ranelate is now rarely used do to the increased risk of heart attacks and strokes in patients with other cardiovascular risk factors. It works by both inhibiting osteoclasts and stimulating osteoblasts.
Strontium is taken as a powder dissolved in water. Side effects include nausea, diarrhoea and occasionally allergic reaction.
Selective Oestrogen Receptor Modulators
Raloxifene is a single daily tablet, which has a similar protective effect on bone as oestrogen. It slows the post-menopausal loss of bone density and limits the risk of osteoporotic fractures. Side effects of raloxifene include hot flushes, cramps and increased risk of thromboembolism.