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BNSSG Adult Joint Formulary

6.4 Disorders of bone metabolism

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Last edited: 07-11-2024

6.4 Drugs affecting bone metabolism

First line drugs

Second line drugs

Specialist drugs

Secondary care drugs

See NICE TA464 which partially updates TA160 and TA161
See NICE TA161 on alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women
See Local guidelines available regarding osteoporosis management and drug holidays located in the Endocrine System guidelines page

Bisphosphonates

Recommended: (TLS Green)

Alendronic acid

Dispersible alendronic acid is non-formulary

Alternatives: (TLS Blue)

Risedronate

NICE TA160 Primary prevention of osteoporotic fragility fractures in postmenopausal women

Specific indications:

Disodium pamidronate (TLS Red)

Hypercalcaemia of malignancy
Osteolytic lesions & bone pain in bone metastases and Paget's disease

Ibandronic acid 3mg injection (TLS Red)

Treatment of osteoporosis in those patients who cannot tolerate oral bisphosphonates and zoledronic acid is contraindicated

Ibandronic acid 2mg injection (TLS Red)

Hypercalcaemia of malignancy in patients with severe renal impairment (<30mL/min)

Ibandronic acid 50mg tablet (TLS Amber 3 months)

Early Postmenopausal breast cancer (SCP click here)

Ibandronic acid 150mg tablet (TLS Blue)

For the treatment of osteoporosis in postmenopausal women at increased risk of fracture when first line alendronate or risedronate are not tolerated

Sodium clodronate (Loron^®or Clasteon^®) (TLS Amber Specialist Initiated)

Hypercalcaemia of malignancy, bone metastases in breast cancer

Sodium clodronate (Clasteon^®or Loron^®) (TLS Red)

Bone related complications of Myeloma

Zoledronic acid (TLS Red)

Hypercalcaemia of malignancy
Prevention of skeletal related events in patients with advanced prostate malignancy involving bone
Consultant Rheumatologist and Specialists in Osteoporosis in those patients who cannot tolerate oral bisphosphonates or where there are compliance issues e.g. cognitively impaired elderly patients
For use in Early Breast Cancer in Postmenopausal women during chemotherapy requiring secondary care attendance

Bone Formation Stimulants

Calcitonins

Recommended: (TLS Red)

Calcitonin salmon (salcatonin) injection

See MHRA information on increased risk of cancer

Monoclonal Antibodies

Specific indications:

Denosumab (TLS Amber 3 months)

To reduce risk of osteoporotic fractures in post-menopausal women as detailed in the NICE TA204 and also in men using the same criteria for treatment detailed in NICE TA204: Denosumab for the prevention of osteoporotic fractures in postmenopausal women. (SCP click here and prescribing information)

Denosumab (TLS Red)

NICE TA265 For prevention of skeletal related events in adults with bone metastases from solid tumours (not including prostate cancer)
See also Guide for adding Denosumab to EMIS Web

Denosumab (TLS Red)

For treatment of malignant hypercalcaemia resistant to bisphosphonates
Unlicensed

Romosozumab (TLS Red)

NICE TA791 Romosozumab for treating severe osteoporosis

Parathyroid hormone

Specific indication: (TLS Red)

Teriparatide

NICE TA161 Secondary prevention of osteoporotic fragility fractures
Teriparatide for Osteoporosis in Men as per Interim Clinical Commissioning Policy Statement
Patients who are contraindicated to romosozumab due to high CVS risk and for use in men that fall outside the NHSE commissioning policy. That is:
- To consider teriparatide for postmenopausal women and men aged >50 years who have had a major osteoporotic fracture within 24 months, with any one of the following:
- a BMD T-Score ≤-3.5 (at the hip or spine), or
- a BMD T-score ≤-2.5 (at the hip or spine) and either
- vertebral fractures (either a vertebral fracture within 24 months or a history of ≥2 osteoporotic vertebral fractures), or
- very high fracture risk (e.g., as quantified by FRAX)
NHSE SSC 2703 Clinical Commissioning Policy 201101: Teriparatide for Osteoporosis in Men (Adults)

Abaloparatide

NICE TA991 Abaloparatide for treating osteoporosis after menopause

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6.4 Disorders of bone metabolism

6.4 Drugs affecting bone metabolism

Bisphosphonates

Alendronic acid

Risedronate

Disodium pamidronate (TLS Red)

Ibandronic acid 3mg injection (TLS Red)

Ibandronic acid 2mg injection (TLS Red)

Ibandronic acid 50mg tablet (TLS Amber 3 months)

Ibandronic acid 150mg tablet (TLS Blue)

Sodium clodronate (Loron® or Clasteon®) (TLS Amber Specialist Initiated)

Sodium clodronate (Clasteon® or Loron®) (TLS Red)

Zoledronic acid (TLS Red)

Bone Formation Stimulants

Calcitonins

Calcitonin salmon (salcatonin) injection

Monoclonal Antibodies

Denosumab (TLS Amber 3 months)

Denosumab (TLS Red)

Denosumab (TLS Red)

Romosozumab (TLS Red)

Parathyroid hormone

Teriparatide

Abaloparatide

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Sodium clodronate (Loron^®or Clasteon^®) (TLS Amber Specialist Initiated)

Sodium clodronate (Clasteon^®or Loron^®) (TLS Red)