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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
               >     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.  


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.  
AMBER     Ibandronic acid tablets 150mg once monthly (Bonviva®) + prescribe  Evacal or  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 Evacal or 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
AMBER     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.


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 public seeking advice on medicine-related matters are advised to speak with their GP, pharmacist, nurse or contact NHS111 Service 
  Email: info.elmmb@nhs.net
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