Bishosphonates

Bisphosphonates are the most widely used family of drugs to reduce fracture risk.

This family of medications includes drugs such as:

• Alendronate or Alendronic Acid (Fosamax). Weekly tablet
• Risedronate (Actonel). Weekly tablet
• Zoledronic acid (Aclasta) Given intravenously and not orally

How do bisphosphonates work?

Bone is constantly being worn away (this is called resorption) by specialist bone cells called osteoclasts and rebuilt (this is called formation) by specialist bone cells called osteoblasts. This complete process is called bone remodelling or turnover. This cycle is taking place all the time throughout our lives. The adult skeleton is normally completely replaced in a 7-10 year period.

Bisphosphonates are attracted to calcium and as approximately 99% of calcium is stored in our bones bisphosphonate therapies are attracted to our bones.  Bisphosphonates work by slowing down the process of bone loss or resorption by inhibiting the cells that break down bone (osteoclasts) and allow the cells (osteoblasts) that rebuild bone or formation to work more effectively. They are usually very effective at reducing fracture risk.

These drugs are required to be taken correctly for usually 5 years before a further DXA scan.

Bisphosphonates and pain

Bisphosphonates are NOT taken to relieve the pain of osteoporotic fractures. They improve or protect bone density and reduce the risk of fractures. Pain relief can be provided by painkillers or analgesia, heat, ice pack or non invasive techniques such as Transcutaneous Electrical Nerve Stimulation or TENS machines. The latter can be bought from local pharmacy departments and are not expensive.

This leaflet will tell you how to take your oral bisphosphonate correctly.

More information of these individual treatments can be found on the Royal Osteoporosis website: theros.org.uk/

Patient Information Leaflet: How to take your oral bisphosphonate correctly (pdf). See section below about taking any calcium supplements.

What should I do if I have any issues?

You should speak to your GP in the first instance and try Risedronate if you have not done so.

The bisphosphonate Zoledronate is given as an intravenous drip in hospital and MAY be a suitable alternative.

You can contact the Osteoporosis Specialist Nurses for advice on

01224 555078 (message service) or gram.osn@nhs.scot

or

The Royal Osteoporosis Society - The UK’s only national charity dedicated to bone health and osteoporosis.

Visit: theros.org.uk

Call: 0800 80 0035

E-mail nurses@theros.org.uk 

Other treatments

Denosumab

Six monthly injection given in Primary Care in NHS Grampian. Not suitable for everyone. Advice should be sought from the Grampian Osteoporosis Service about commencing.

Note: It must be given regularly and NOT stopped or significantly delayed. A blood test is required before each injection.

More information of this treatment can be found on the Royal Osteoporosis website: theros.org.uk

Anabolic treatments

These are treatments that encourage the body to make additional bone and reduce fracture risk rather than just slowing the loss of bone. They are both injectable treatments and must be prescribed through the NHS Grampian Bone Service.

Teriparatide

This is not suitable for everyone. It is a daily injection into the skin usually for a two year period. A further treatment is required after the course completes to lock in any benefit gained.

More information of this treatment can be found on the Royal Osteoporosis website: theros.org.uk

Romosozumab

This is not suitable for everyone. It is TWO injections given monthly into the skin usually for a one year period. A further treatment is required after the course completes to lock in any benefits. More information of this treatment can be found on the Royal Osteoporosis website: theros.org.uk

Calcium and Vitamin D

These are often prescribed alongside other Osteoporosis Medications. Adequate amounts are important for keeping bones healthy and can help the effectiveness of other osteoporosis medications.

Calcium

The best source of calcium is diet. Dairy products are rich in Calcium but many other also have Calcium. A normal healthy adult’s recommended intake is an AVERAGE of 700mg a day.

You can calculate your average daily intake using this questionnaire:

NHS Grampian Calcium Questionnaire (pdf)

or at

The International Osteoporosis Foundation

Guidance on calcium rich foods and calcium content of foods can be found at:

The British Association of UK Dieticians (BDA)

The International Osteoporosis Foundation

Calcium rich foods for a gluten free diet, dairy free diet and vegan diet

Oxford University Hospital NHS Trust has, in association with their dieticians, produced some factsheets regarding calcium rich foods for these diets. They have given permission to share these.

Vitamin D

Vitamin D is important as it helps the absorption of calcium from the gut and helps to maintain correct levels of calcium in our bodies and is important in the function of our nerves and muscles.  The main source of Vitamin D is from sunlight which triggers processes in the body to make the active form of Vitamin D. Approx 80-90% of our Vitamin D is made from sunlight exposure and the remainder comes from our diet. Foods that contain Vitamin D are egg yolks, oily fish such as salmon, mackerel and tuna and some fortified foods such as breakfast cereals, margarine and baby milk. 

The effective exposure of Vitamin D in the UK only occurs during the months of May – September and Vitamin D is stored and released over the winter months and supplemented by any dietary intake. The current recommendation is sun exposure during May – September for 10 minutes a day on the face and arms, without sunscreen and taking care not to burn and can be achieved by an active, outdoors lifestyle. Supplements of at least 400IU or 10mcg will usually maintain a current Vitamin D level and in those with Osteoporosis this may be increased to 800IU daily or equivalent. The Vitamin D level can be checked by a simple blood test. However, the results are centrally analysed in Scotland in Glasgow and results can take sometimes take 4 weeks or more to be obtained. They CANNOT be repeated more than once a year.

Vitamin D only preparations

In certain cases where osteoporosis medication is prescribed and calcium intake has been checked by calcium questionnaire and very good (approx 700-1000 mgs per day) a pure vitamin D preparation may be adequate.

Combined Calcium and Vitamin D preparations

A number of combined preparations available which may be swallowed, chewed, sucked or taken as a drink. If they are not contraindicated and are prescribed for you then it is important to find one that suits you. Speak to your GP or Pharmacist if you are struggling.

Taking your Calcium and Vitamin D

It is important to take these regularly. Generally a dose will be split into two doses but they can be taken as one dose although they can sometimes cause tummy ache if taken this way. For best absorption, they should be taken before or with food. It is important to find one to suit you so please ask your GP for an alternative if this is the case rather than just stopping.

Taking Calcium and Vitamin D if taking Oral bisphosphonates

It is important NOT to take these at the same time as your bisphosphonate tablet. You should wait at least 2 hours after. This is because bisphosphonate drugs are attracted to calcium and therefore they will not be properly absorbed if you do this as they are attracted to the supplement and not bones.

If it helps you can get into a routine of taking your calcium and vitamin D tablets at lunchtime and teatime and then this will not interfere with the day of your weekly early morning bisphosphonate tablet is due.

Reducing Fracture risk with Calcium and Vitamin D Supplements

There is limited evidence that Calcium and Vitamin D supplements alone will reduce fracture risk in the majority of people but they are important for good bone health.

However, supplementation of Vitamin D in the institutionalised or housebound elderly can also help reduce the risk of falls and along with calcium supplementation in the elderly can also decrease the risk of hip fracture without any additional medication.

 

Published: 19/05/2022 11:41