NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Prescribing
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6 Endocrine system

6.6 Drugs affecting bone metabolism

6.6.1 Calcitonin and parathyroid hormone

Total Formulary
PARATHYROID HORMONE (PROTEACT)

Restrictions: Restricted to specialist use for the treatment of severe osteoporosis in women with at least two prior vertebral fractures or equivalent high risk according to local prescribing protocol. The use for the treatment of osteoporosis in men is unlicensed and therefore non-Formulary.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/129904.htm

TERIPARATIDE (FORSTEO)

Restrictions: Restricted to specialist use for the treatment of established severe osteoporosis in post-menopausal women for whom parathyroid hormone (PTH 1-84) is not tolerated or appropriate. The treatment of osteoporosis associated with glucocorticoid therapy and the treatment of osteoporosis in men at increased risk of fracture is not recommended by SMC and is non-Formulary.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/128203.htm

6.6.2 Bisphosphonates and other drugs affecting bone metabolism

Preferred list
ALENDRONIC ACID (tablets)

Prescribing Notes:

First line bisphosphonate for osteoporosis. The 70mg once a week standard tablet preparation is the preferred formulation (except in men, where only the daily 10mg preparation is licensed).

For other preparations, see the Total Formulary

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/36236.htm

RISEDRONATE SODIUM

Prescribing Notes:

Risedronate is the second line bisphosphonate for osteoporosis and should only be used in patients who either fail to tolerate alendronic acid because of gastrointestinal side effects or when alendronic acid is considered inappropriate because of existing active dyspeptic symptoms. Treatment of osteoporosis in men at high risk of fractures remains non-Formulary.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/86573.htm

Total Formulary
IBANDRONIC ACID

Restrictions: Restricted to specialist initiation. The use of the injection for osteoporosis is restricted to use in patients who are unsuitable for or unable to tolerate oral treatment options for osteoporosis. Treatment initiation should be under specialist supervision. Restricted to second line use by specialist oncologists for prevention of skeletal events in patients with breast cancer and metastatic bone cancer and to consultants treating tumour induced hypercalcaemia.

Prescribing Notes:

Excludes Bonviva® tablets.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/106507.htm

ALENDRONIC ACID (BINOSTO) (effervescent tablets)

Restrictions: Restricted to patients who are unable to swallow tablets where alendronic acid is the appropriate treatment choice

Prescribing Notes:

  • Please note that the effervescent formulation is subject to the same administration requirements as the standard tablets.
  • The cost differential between the effervescent tablet and the standard tablet formulation is significant. Consider whether alternative non-oral options may be more suitable (may require discussion with specialist service).

CLODRONATE

Restrictions: Restricted to specialist initiation.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/4454.htm

DENOSUMAB (PROLIA/XGEVA) (injection)

Restrictions: See Prescribing notes for Formulary indications and restrictions on use.

Prescribing Notes:

Formulary Indications:

  • Osteoporosis: Use in the treatment of osteoporosis in postmenopausal women in restricted to use in those patients for whom oral bisphosphonates are unsuitable, contraindicated or not tolerated in accordance with local protocol.  A shared care agreement is in place for this indication and can be accessed here.
  • Skeletal-related events: The prevention of skeletal related events in adults with bone metastases from solid tumours is restricted to specialist use in accordance with regional protocol where zoledronic acid is not appropriate (for example, due to renal impairment or venous access problems). Use for this indication remains specialist use only.

Non-Formulary indications:

  • Bone loss in prostate cancer: Use in the treatment of bone loss associated with hormone ablation in men with prostate cancer at increased risk of fractures is not recommended by SMC and remains non-Formulary.
  • Osteoporosis in men at increased risk of fractures is not recommended by SMC and remains non-Formulary.
  • Giant cell tumour of bone: in adults and skeletally mature adolescents when the condition is unresectable or where surgical resection is likely to result in severe morbidity is not recommended by SMC and remains non-Formulary.

SMC advice pertaining to denosumab can be accessed here

NICE Mutiple Technology Appraisals pertaining to denosumab can be accessed here

BNF Link: https://www.medicinescomplete.com/mc/bnf/current/PHP4691-denosumab.htm?q=denosumab&t=search&ss=text&p=1#_hit

ZOLEDRONIC ACID

Restrictions: Restricted as detailed in the prescribing notes below.

Prescribing Notes:

Formulary indications:

  • Prevention of skeletal related events: in adult patient with with solid tumours with symptomatic bone metastases in accordance with regional guidelines. 
  • Osteoporosis: treatment in post-menopausal women is restricted to specialist use in patients who are unsuitable for or unable to tolerate oral treatment options.
  • Paget’s disease: treatment is restricted to specialist use only.  

Non-Formulary indications:  

  • The treatment of men at inceased risk of fracture, including those with a recent low-trauma hip fracture, is not recommended by SMC.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/106146.htm