Desmospray c (Ferring) A family history of osteoporosis, and early menopause.

6 Desmospray c (Ferring) A family history of osteoporosis, and early menopause.

Nasal spray , desmopressin acetate 10 micrograms/ metered spray. Net price 6-mL unit (60 metered

Those at risk of osteoporosis should maintain an sprays) = £26.04. Counselling, fluid intake, see above

adequate intake of calcium and vitamin D and any Note Children requiring dose of less than 10 micrograms should

deficiency should be corrected by increasing dietary be given DDAVP

intranasal solution intake or taking supplements. Octim c (Ferring) A

Nasal spray , desmopressin acetate 150 micrograms/ Elderly patients, especially those who are housebound metered spray, net price 2.5-mL unit (25 metered

or live in residential or nursing homes, are at increased sprays) = £600.00. Counselling, fluid intake, see above

risk of calcium and vitamin D deficiency and may benefit from supplements (section 9.5.1.1 and section

Injection , desmopressin acetate 15 micrograms/mL, 9.6.4). Reversible secondary causes of osteoporosis net price 1-mL amp = £20.00

such as hyperthyroidism, hyperparathyroidism, osteo- malacia or hypogonadism should be excluded, in both

TERLIPRESSIN

men and women, before treatment for osteoporosis is initiated.

Indications bleeding from oesophageal varices Cautions see under Vasopressin Contra-indications see under Vasopressin

Postmenopausal osteoporosis The bisphosphon- Side-effects see under Vasopressin, but effects milder

ates (alendronic acid, disodium etidronate, and risedro- Dose

nate, section 6.6.2) are effective for preventing postme- . By intravenous injection , 2 mg followed by 1 or 2 mg

osteoporosis. Hormone replacement every 4 to 6 hours until bleeding is controlled, for up

nopausal

therapy (HRT section 6.4.1.1) is an option where to 72 hours other therapies are contra-indicated, cannot be toler- ated, or if there is a lack of response. The CSM has Glypressin c (Ferring) A advised that HRT should not be considered first-line

Injection , terlipressin, powder for reconstitution. Net therapy for long-term prevention of osteoporosis in price 1-mg vial with 5 mL diluent = £19.44 (hosp. only)

women over 50 years of age. HRT is of most benefit for the prophylaxis of postmenopausal osteoporosis if started early in menopause and continued for up to 5

Antidiuretic hormone antagonists

years, but bone loss resumes (possibly at an accelerated rate) on stopping HRT. Calcitonin (section 6.6.1) may

Demeclocycline (section 5.1.3) can be used in the

be considered for those at high risk of osteoporosis for treatment of hyponatraemia resulting from inappropri-

whom a bisphosphonate is unsuitable. Women of Afro- ate secretion of antidiuretic hormone, if fluid restriction

Caribbean origin appear to be less susceptible to osteo- alone does not restore sodium concentration or is not

porosis than those who are white or of Asian origin.

Postmenopausal osteoporosis may be treated with a bisphosphonate (section 6.6.2). The bisphosphonates (such as alendronate, etidronate, and risedronate) decrease the risk of vertebral fracture; alendronate and risedronate have also been shown to reduce non-ver- tebral fractures. If bisphosphonates are unsuitable calci- triol (section 9.6.4), calcitonin or strontium ranelate (section 6.6.2) may be considered. Calcitonin [unli- censed indication] may also be useful for pain relief for up to 3 months after a vertebral fracture if other analgesics are ineffective. Parathyroid hormone, and teriparatide (section 6.6.1) have been introduced for the treatment of postmenopausal osteoporosis.

Raloxifene (section 6.4.1.1) is licensed for the prophy- laxis and treatment of vertebral fractures in postmeno- pausal women.

NICE guidance Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women (October 2008) Alendronate is recommended as a treatment option

for the primary prevention of osteoporotic fractures in the following susceptible postmenopausal women: .

Women over 70 years who have an independent risk factor for fracture (parental history of hip fracture, alcohol intake of 4 or more units per day, or rheumatoid arthritis) or an indicator of low bone mineral density (body mass index under 22 kg/m , ankylosing spondylitis, Crohn’s disease, prolonged immobility, untreated prema- ture menopause, or rheumatoid arthritis) and confirmed osteoporosis

. Women aged 65–69 years who have an inde- pendent risk factor for fracture and confirmed osteoporosis

. Women under 65 years who have an indepen- dent risk factor for fracture and at least one additional indicator of low bone mineral density and confirmed osteoporosis

Risedronate or etidronate are recommended as alternatives for women: .

in whom alendronate is contra-indicated or not tolerated and

. who comply with particular combinations of bone mineral density measurement, age, and independent risk factors for fracture, as indi-

cated in the full NICE guidance 1

Strontium ranelate is recommended as an alterna- tive for women: .

in whom alendronate and either risedronate or editronate are contra-indicated or not tolerated

and .

who comply with particular combinations of bone mineral density measurement, age, and independent risk factors for fracture, as indi-

cated in the full NICE guidance 1

Raloxifene is not recommended as a treatment option in postmenopausal women for primary pre- vention of osteoporotic fractures.

NICE guidance Alendronate, etidronate, risedronate, raloxifene, strontium ranelate, and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women (October 2008) This guideline recommends treatment options for the secondary prevention of osteoporotic fractures in postmenopausal women with confirmed osteo- porosis who have also sustained a clinically apparent osteoporotic fracture. Alendronate is recommended as a treatment option for the secondary prevention of osteoporotic frac- tures in susceptible postmenupausal women. Risedronate or etidronate are recommended as alternatives for women: .

in whom alendronate is contra-indicated or not tolerated and

who comply with particular combinations of bone mineral density measurement, age, and independent risk factors for fracture (parental history of hip fracture, alcohol intake of 4 or more units per day, or rheumatoid arthritis, as

indicated in the full NICE guidance 2

Strontium ranelate or raloxifene are recom- mended as alternatives for women: .

in whom alendronate and either risedronate or editronate are contra-indicated or not tolerated and

who comply with particular combinations of bone mineral density measurement, age, and independent risk factors for fracture, as indi-

cated in the full NICE guidance 2

Teriparatide is recommended as an alternative for women: .

in whom alendronate and either risedronate or editronate, or strontium ranelate are contra-indi- cated or not tolerated, or where treatment with alendronate, risedronate or editronate has been unsatisfactory (indicated by another fragility fracture and a decline in bone mineral density despite treatment for 1 year) and

who comply with particular combinations of bone mineral density measurement, age, and number of fractures, as indicated in the full