Kent and medway osteoporosis network
Kent and Medway Osteoporosis Network Primary Care Guidelines for the
Secondary Prevention of Osteoporosis in Post-menopausal Women
Alendronic Acid 70mg once weekly
ed, poorly tolerated, not effective^ or poor concordance
Contraindicated, poorly tolerated, not effective or poor concordance
Patients who develop multiple fractures whilst receiving treatment may need referral for DEXA and
consideration of alternative treatment such as Teriparatide or PTH *
see K&M guidance for prescribing criteria http://www.kentmedway.nhs.uk/welcome/for-professionals/prescribing/
Always prescribe calcium and vitamin D for all patien ts receiving treatment for osteoporosis unless dietary
intake of both is deemed adequate. Kent and Medway
PCTs preferred products are Adcal D3 tablets (one tablet
twice a day) or Calfov
it sachets (one sachet once a day).
Ibandronic acid▼ 150mg once monthly should only be pres cribed for patients who wish to take a monthly tablet who are
aged under 75 years who are not at increased risk of
falling. Ibandronic acid has only been shown to reduce vertebral
fractures in clinical trials. The UK licensed doses of ibandronic acid have not demonstrated fracture reduction.
Disodium etidronate (Didronel) is not recommended in
this guideline. Disodium etidronate has not been shown in
clinical trials to be as effective as either alendronic acid
or risedronate sodium in preventing non-vertebral fractures.
Recommend : • regular weight-bearing exercise e.g. brisk walking, jogging, dancing • stop smoking • reduce alcohol intake
▼ Black Triangle Drugs. There is limited experience of the use of these products and all suspected adverse reactions should be reported to the Commission on Human Medicines (CHM) through the Yellow Card Scheme. Please refer to the full prescribing information prior to prescribing any of these products.
Selected contraindications and cautions Drug Contraindications
Upper GI disorders (dysphagia, symptomatic
factors which delay emptying e.g. stricture,
oesophageal disease, gastritis, duodenitis or
achalasia; hypocalcaemia; inability to stand
ulcers, history (within one year) of ulcers, active GI
bleeding, upper GI surgery, renal impairment
Consider preventive dental treatment before initiating (risk of osteonecrosis of the jaw); renal impairment; monitor renal function, calcium, phosphate and magnesium; cardiac disease (avoid fluid overload)
Oesophageal abnormalities and other factors which delay transit or emptying e.g. stricture or achalasia, renal impairment
Predisposition to thromboembolism, renal impairment. Serious allergic skin reactions – stop treatment immediately if rash develops.
Moderate renal impairment (avoid if severe)
malignancies of bone metastases, metabolic bone diseases including Paget’s disease and hyperparathyroidism, unexplained raised alkaline phosphatase, previous radiation therapy to the skeleton
Renal impairment, severe hepatic impairment, cardiac disease, hypocalcaemia
Prescribing in renal impairment
information / clinical experience
Not recommended if CrCl <35ml/min due to
Very little evidence is available on use in renal
impairment. A sub-analysis of a recent trial showed there was no increase in adverse events in women with eGFR <45ml/min.
A comparison of oral and intravenous ibandronic
acid in PMO showed renal and urinary adverse
impairment where creatinine clearance is
reactions to be uncommon and comparable in
frequency across all treatment arms (2-3%). No
recommended for use in patients who have a cases of acute renal failure were reported. It has creatinine clearance below 30 ml/min,
been suggested that, due to the lack of clinical
experience with ibandronate, it may be prudent to use an alternative bisphosphonate in renally impaired patients.
Should not be in severe renal impairment (no
Experience has found risedronate may be used in mild renal impairment (CrCl 20-50ml/min); half of the usual dose has been used where CrCl 10-20ml/min. The author of a recent study has been suggested treatment to be safe in patients with CrCl 15-30ml/min.
Not recommended if CrCl <30ml/min, no
There is some evidence to suggest naturally
dose adjustment required if CrCl 30-70ml/min occurring strontium may accumulate in patients
with renal impairment but the clinical consequence of this is uncertain.
Contraindicated in severe renal impairment
Zoledronic acid prescribed for PMO has not been shown to impair renal function compared to placebo, when monitored over a three-year period. However, it has been associated with renal toxicity when used in higher doses for the management of malignancies.
References BNF 55 (March 2008) Manufacturers Summary of ProducNICE Appraisal Consultation Document Osteoporosis – Secondary Prevention Including Strontium Ranelate (March 2008) London New Drugs Group APC/DTC Briefing Document Comparison of Bisphosphonates and Strontium Ranelate for Osteoporosis May 2007 Drug Update Which Bisphosphonate for osteoporosis 2008 (57) Regional Drug and Therapeutics Centre UKMI Q&A 169.1 Can oral bisphosphonates be given to patients with renal impairment for the management of osteoporosis? UKMI Q&A 124.1 Can strontium ranelate be given to patients with renal impairment or patients on renal replacement therapies? Safer Medication Use No.2 Bisphosphonates for osteoporosis
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