6.6 Drugs affecting bone metabolism

6.6.1 Calcitonin
Calcitonin (Salmon) injection 100u/1ml, 200u/1ml	F

6.6.2 Bisphosphonates
Alendronic acid tablets 10mg, 70mg	F	Counselling required Use 2nd line to risedronate
Didronel PMO tablets	F	Counselling required
Pamidronate injection 15mg/5ml	F
Risedronate tablets 5mg, 30mg, 35mg	F	Counselling required 1st line bisphosphonate
Sodium clodronate 800mg tablets (Bonefos)	R	Haematology for multiple myeloma
Strontium ranelate granules 2g	R	For patients intolerant of bisphosphonates
Teriparatide injection 750mcg/3ml prefilled pen	R	Refer to Dr A Ismail
Zoledronic acid infusion 4mg	R	Out-Patient Use Only

For the prophylaxis and treatment of osteoporosis, alendronic acid or risedronate are considered the drugs of choice and can be given daily or weekly. Risedronate is preferred as a first line as it is probably slightly safer in terms of development of oesophagitis and is slight less expensive than alendronate.

For osteoporosis prophylaxis in the elderly living alone, calcium plus 800units of vitamin D3 should be considered (See 9.5.1).

Consider concomitant calcium supplementation with the former agents if diet is insufficient , but do not give at the same time of day.

Bisphosphonates may cause oesophagitis; so patients must be counselled to sit upright and swallow tablets whole with a full glass of water.