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Chronic Kidney Disease and bone conditions

Chronic Kidney Disease and bone conditions

Chronic Kidney Disease NICE CG73

Bone Conditions

Bisphosphonates appear to have benefits in people with CKD without an increased risk of adverse effects:

  • use when needed for the prevention and treatment of osteoporosis in people with stage 1, 2, 3A or 3B Chronic Kidney Disease
  • check the Summary of Product Characteristics for any recommendations on dose adjustment according to GFR

When needed, give vitamin D supplementation as follows:

  • stage 1, 2, 3A or 3B CKD - cholecalciferol or ergocalciferol,

  • stage 4 or 5 CKD - alfacalcidol or calcitriol.  

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Ibandronic acid 

Oral Ibandronic acid

Ibandronic acid is recommended for the treatment of post menopausal osteoporosis to prevent vertebral fractures when a weekly bisphosphonate is not tolerated or where there is poor adherence.  Only to be initiated on the recommendation of a specialist. Recommendation may involve discussion with a GP over the telephone or by letter.  Efficacy on femoral neck (hip) fractures has not been established.  See full review online  - click here to access it.

AMBER     Ibandronic acid tablets 150mg once monthly (Bonviva®) + prescribe Adcal D3 1 tab twice daily

Intravenous Zoledronic  acid

Intravenous zoledronate should only be initiated and prescribed by a specialist in the management of osteoporosis.  It should be used in preference to pamidronate for the treatment of osteoporosis in postmenopausal women in all new patients. It is also indicated for treating osteoporosis in men. It should be reserved for patients who are intolerant, unresponsive or unsuitable for oral treatment with bisphosphonates and other oral treatments such as strontium ranelate.  Patients must still receive supplemental calcium and vitamin D. 

RED           Zoledronic acid injection 5mg annually (Aclasta®)

                           + prescribe Adcal D3 1 tab twice daily

For the treatment of bone pain in cancer

AMBER     Sodium clodronate capsules 400mg (Bonefos®)

For the treatment of bone metastases in breast cancer

SHARED CARE    Ibandronic acid tablets 50mg daily (Bondronat®)

Zoledronic Acid

For the treatment of hypercalcaemia of malignancy and bone damage in advanced malignancies

RED           Zoledronic acid injection 4mg (Zometa®)

Caution - There are two different strengths of IV zoledronic acid, please ensure you have selected the right strength.

For the treatment of Paget’s disease of the bone

Zoledronic acid should be prescribed only by physicians with experience in treatment of Paget's disease of the bone in line with its licensed indication.  It may be used first line, or as subsequent therapy in patients for whom other treatments are not tolerated, ineffective or inappropriate. Patients must be appropriately hydrated prior to administration of zoledronic acid and this is especially important for patients receiving diuretic therapy. In addition, it is advised that supplemental calcium corresponding to at least 500 mg elemental calcium twice daily (with vitamin D) is prescribed for patients with Paget's disease for at least 10 days following administration of zoledronic acid.  For further recommendations on the use of zoledronic acid 5mg for Paget's disease, refer to the new drug review which can be accessed online at www.elmmb.nhs.uk.

RED           Zoledronic acid injection 5mg (Aclasta®)

Caution - There are two different strengths of IV zoledronic acid, please ensure you have selected the right strength.