Bisphosphonates, raloxifene and teriparatide for treating osteoporosis

This summary is based on 3 recent NICE guidelines:

Previous guidance was rather complicated in that different bisphosphonates could be used at different levels of risk. This has all been simplified as the cost of the drugs has reduced. Advice on using raloxifene and teriparatide hasn't changed. Strontium and etidronate are no longer marketed in the UK.

There is quite a nice decision aid that can be used with patients on what the risk reduction is with different treatments.

Who is eligible for bisphosphonate treatment?

A patient must be eligible for risk assessment for osteoporosis. See my summary from 2012 on this. The most obvious patients (and there is a much longer list than this) will be:

  • People who've already had a fragility fracture.
  • Women over 65.
  • Men over 75.
  • People under 50 with current or frequent corticosteroid use, untreated premature menopause or a previous fragility fracture.

Oral bisphosphonates are cost-effective if the risk of fracture (using FRAX or QFracture) is at least 1%.

Intravenous bisphosphonates are cost-effective if the risk is at least 10%, or if the risk is at least 1% and they are unable to take oral bisphosphonates.

Who should actually be offered bisphosphonates?

Patients may be eligible as above in terms of cost-effectiveness, but that doesn't mean we should treat them. They advise that we still use the treatment thresholds from NOGG (National Osteoporosis guideline group) to decide whether to start treatment.

Use the FRAX tool (or QFracture) to determine their risk and what management is advised. My guideline summary from 2012 (the same as for the assessment of risk) gives more guidance on this.

Want a quick reminder on what bisphosphonates are available?

There's a handy table in the guideline. It is worth noting that they have different indications.

  • Alendronic acid 10mg OD, 70mg weekly, oral solution.
  • Ibandronic acid 150mg once a month, injection 3 monthly.
  • Risedronate 5mg OD, 35mg weekly.
  • Zoledronic acid iv, once a year.

Other drugs used in osteoporosis.

Raloxifene.

This isn't advised for use in primary prevention.

It can be used for secondary prevention if the patient meets certain criteria. They are rather complicated, so I haven't listed them here. You can use raloxifene as an alternative when patients can't take a bisphosphonate. You can decide if they are eligible depending on their T-score and their risk factors. There is a table at point 1.3 in the guidance that you can use to judge eligibility.

Teriparatide.

This isn't advised for use in primary prevention.

Again, it can be used for secondary prevention if the patient meets certain criteria. The criteria are, once more, complicated. You can use it in patients who can't take a bisphosphonate, but also in patients who have had an unsatisfactory response to them (eg another fragility fracture and decline in BMD despite having had treatment for a year). There is a paragraph at point 1.4 in the guidance that you can use to judge eligibility.

Strontium and etidronate are no longer marketed in the UK. They were available in previous guidance.

 

 

I’m a freelance GP locum in Winchester & Southampton.

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