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BNSSG Adult Joint Formulary

6.4 Disorders of bone metabolism

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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



Recommended: (TLS Green)

Alendronic acid

  • Dispersible alendronic acid is non-formulary

Alternatives: (TLS Blue)


  • 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)

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 (Bonefos®) (TLS Green)

  • Hypercalcaemia of malignancy, bone metastases in breast cancer

Sodium clodronate (Bonefos®) (TLS Amber)

  • Osteoporosis, Corticosteroid induced osteoporosis and Paget's

Sodium clodronate (Loron®) (TLS Amber)

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



Recommended: (TLS Red)

Calcitonin salmon (salcatonin) injection

 Specific indication: (TLS Red)



Monoclonal Antibodies

Specific indications: 

Denosumab (TLS Amber 3 months)

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)


  • NICE TA161 Secondary prevention of osteoporotic fragility fractures 


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