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Nottinghamshire Area Prescribing Committee
Joint Formulary
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 Formulary Chapter 6: Endocrine system - Full Chapter
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06.06.02  Expand sub section  Bisphosphonates and other drugs affecting bone metabolism
06.06.02  Expand sub section  Bisphosphonates
Alendronic Acid
(Once-Weekly)
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First Choice
Green

Tablet, effervescent tablet

  • Green - Treatment of post menopausal osteoporosis.
  • Follow local osteoporosis guidelines and NICE guidance.
  • Effervescent tablets (Binosto®) available for patients unable to swallow the tablets. Liquid also available, but less cost effective. 
  • If necessary, tablets disperse in 10 mL of water within 2–5 minutes to give very fine particles that disperse easily (unlicensed). Further general information on dispersing tablets.
 
Zoledronic Acid
(5mg - Osteoporosis/Paget's)
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Formulary
Red
Homecare

Infusion 5mg/100mL

  • Approved for Paget's disease.
  • Osteoporosis (once a year). May be initiated only by osteoporosis specialists as per local osteoporosis guidelines.
  • Primary care administration only where CCG pathway exists.

  • Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information
 
Link  Link to reviews
Link  Osteonecrosis of the jaw patient reminder cards
Link  MHRA: osteonecrosis of the jaw - risk minimisation (July 15)
   
Risedronate
(once weekly)
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Formulary
Green

Tablet

  • Second line behind generic alendronate / zoledronic acid
  • Licensed for treatment of osteoporosis. Prevention of osteoporosis post menopause only daily licensed
  • Green - Treatment of post menopausal osteoporosis.
  • Follow local osteoporosis guidelines and NICE guidance.
 
   
Clodronate
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Formulary
Amber 2

Capsule - 400mg
Tablet - 520mg or 800mg

  • Amber 2 - Hypercalcaemia, bone pain associated with metastases
  • Not licensed for osteoporosis
 
   
Ibandronic Acid
(osteoporosis)
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Restricted Drug Restricted
Amber 2

150mg tablet (monthly)

 
Link  Link to reviews
   
Ibandronic Acid
(oncology)
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Restricted Drug Restricted
Amber 2

50mg tablet (daily)

  • Restricted for oncology patients
  • Amber 2 - Reduction of bone damage in bone metastases in breast cancer
  • Red- Adjuvant treatment of breast cancer. Clinically approved by APC July 2020, but awaiting approval of business case for primary care prescribing.
 
   
Ibandronic Acid injection (Bonviva)
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Restricted Drug Restricted
Red
Injection
NUH:
  • Restricted for osteoporosis in patients intolerant of oral bisphosphonate or in place of disodium pamidronate, which is unlicensed
    SFH:
  • For initiation only by osteoporosis specialist for patients in whom yearly zoledronic acid isn't suitable.
  • Red - as per local osteoporosis guidance and notes above
     
  • Link  Click here for independent reviews
    Link  MHRA: osteonecrosis of the jaw - risk minimisation (July 15)
       
    Pamidronate
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Infusion. Secondary care only, not licensed for osteoporosis
  • NUH: First line for tumour-induced hypercalcaemia
  • SFH: Stocked for use in paediatrics (unlicensed) and Paget's disease.
  • SFH: Administration information
     
  • Link  MHRA: osteonecrosis of the jaw - risk minimisation (July 15)
       
    Risedronate
    (daily for Paget's)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2
    Tablet
  • For Paget's disease of the bone
     
  •    
    Zoledronic Acid (4mg - hypercalcaemia/malignancy)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red

    Infusion - 4mg

    • SFH: First line for tumour-induced hypercalcaemia
    • Reduction of bone damage in advanced malignancies involving bone, hypercalcaemia of malignancy
    • Available through NUH only: Adjuvant bisphosphonate therapy in post-menopausal women with breast cancer in accordance with NICE guideline 101.
     
    Link  NICE NG101: Early and locally advanced breast cancer: diagnosis and management
    Link  Osteonecrosis of the jaw patient reminder cards
    Link  SFH: Zoledronic acid for hypercalcaemia
       
    06.06.02  Expand sub section  Denosumab
    06.06.02  Expand sub section  Strontium ranelate
     ....
     Non Formulary Items
    Alendronic Acid
    (Once Daily)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Alendronic Acid with colecalciferol  (Fosavance)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Tablet
  • Needs to be given with daily calcium, and Adcal D3 contains sufficient vit D.
  • Costs 23pm. (vs 1.30 for alendronate alone)
  •  
    Disodium Etidronate  (Didronel PMO)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Ibandronic acid IV infusion  (Bondronat)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Reduction of bone damage in bone metastases in breast cancer
     
    Tiludronic Acid  (Skelid)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Grey for Paget's disease of bone
     
      
    Key
    note Notes
    Section Title Section Title (top level)
    Section Title Section Title (sub level)
    First Choice Item First Choice item
    Non Formulary Item Non Formulary section
    Restricted Drug
    Restricted Drug
    Unlicensed Drug
    Unlicensed
    Track Changes
    Display tracking information
    click to search medicines.org.uk
    Link to adult BNF
    click to search medicines.org.uk
    Link to children's BNF
    click to search medicines.org.uk
    Link to SPCs
    SMC
    Scottish Medicines Consortium
    Cytotoxic Drug
    Cytotoxic Drug
    CD
    Controlled Drug
    High Cost Medicine
    High Cost Medicine
    Cancer Drugs Fund
    Cancer Drugs Fund
    NHSE
    NHS England
    Homecare
    Homecare
    CCG
    CCG

    Traffic Light Status Information

    Status Description

    Grey

    Grey / Non-Formulary: Medicines, which the Nottinghamshire APC has actively reviewed and does not recommend for use at present due to limited clinical and/or cost effective data.
    Grey / Non-Formulary (undergoing assessment): Work is ongoing and will be reviewed at a future APC meeting.
    Grey / Non-Formulary (no formal assessment): APC has not formally reviewed this medicine or indication because it had never been requested for formulary inclusion. Often used for drugs new to market.
      

    Red

    Medicines which should normally be prescribed by specialists only. eg hospital only.
    For patients already receiving prescriptions in primary care - continue. No new patients to receive prescriptions in primary care.
      

    Amber 1

    Medicines that should be initiated by a specialist and prescribed by primary care prescribers only under a shared care protocol, once the patient has been stabilised.
    Prior agreement must be obtained by the specialist from the primary care provider before prescribing responsibility is transferred. The shared care protocol must have been agreed by the relevant secondary care trust Drugs and Therapeutics Committee(s) (DTC) and approved by the Nottinghamshire APC.
      

    Amber 2

    Medicines suitable to be prescribed in primary care / general practice after specialist* recommendation or initiation.
    A supporting prescribing guideline may be requested which must have been agreed by the relevant secondary care trust DTCs and approved by the Nottinghamshire APC.
    *Specialist is defined by the APC as a clinician who has undertaken an appropriate formal qualification or recognised training programme within the described area of practice
      

    Amber 3

    Primary care/ non specialist may initiate as per APC guideline.
    The supporting prescribing guideline must have been agreed by the relevant secondary care trust D&TC(s) and approved by the Nottinghamshire APC.
      

    Green

    Medicines suitable for routine use within primary care.
    Can be initiated within primary care within their licensed indication, in accordance with nationally recognised formularies, for example the BNF, BNF for Children, Medicines for Children or Palliative Care Formulary. Primary care prescribers take full responsibility for prescribing.   

    OTC

      

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