The patient may have been prescribed the medicine in the past but not wanted to take it; this question creates an opportunity for concerns to be aired and answered

This is also an opportunity to check that a contraindication or caution to the medication has not been overlooked at the prescribing stage. For example, the risk of oesophageal reactions with bisphosphonates means that they should be used very carefully in people with an upper GI problem such as dysphagia, gastritis, peptic ulceration, Barrett’s oesophagus and recent major GI disease or upper GI surgery.

Bisphosphonates have very specific administration instructions due to the risk of gastrointestinal side-effects when taken orally. The general advice is to take an oral product after an overnight fast and at least 30 minutes before any other medication or first food or drink of the day (other than water).

Tablets should be swallowed whole with a full glass of water (around 200ml) or dissolved in half a glass of water (around 120ml) if effervescent, while the patient stands or sits in an upright position, and they should not lie down for another 30 minutes (an hour for ibandronate). 

Explaining how this can fit into their morning routine is helpful. (Note: some bisphosphonates are administered intravenously.)

Strontium ranelate should be taken at least two hours after the last meal of the day, so is usually taken at bedtime. It does no harm to work out with the patient how this fits into their evening routine, given the huge variability in the times individuals eat and go to bed. The product is available as granules that need to be dissolved
in at least 30ml of water before being taken

Denosumab is administered subcutaneously into the thigh, abdomen or upper arm every six months when prescribed for osteoporosis. Only a small number of people self-administer, and only then if enrolled in the manufacturer’s patient support programme.

OP medication dosing regimens vary widely and it can be more difficult to remember to take something that is prescribed weekly (or even less frequently) than a daily product. It is worthwhile helping the patient to identify when they are going to take their medication and how they will set up systems to ensure they don’t forget e.g. writing it on a calendar, setting an audible reminder on a smart speaker, or involving carers or family members.

Giving advice here is key as patients may be fearful about seeking help if the situation arises. A double dose should not be taken to compensate for the one that has been missed

Bisphosphonates, if taken daily, should be continued the next day as usual when remembered, as should strontium ranelate. If taken less frequently, the next tablet should be taken on the day that it is remembered and then dosing resumed on the day it is normally taken

Denosumab has some flexibility with dosing, but the benefits can wear off relatively quickly – so it is recommended that a missed dose isn’t delayed by more than four weeks.

This question establishes whether the patient understands the long-term nature of this medication use (this may not be the case if taken alongside steroid treatment) and is an opportunity to emphasise the importance of continuing treatment even when the benefits may not be apparent. This is particularly relevant if the medicine has been prescribed preemptively when talking about maintaining current activities and remaining independent.

Bisphosphonate therapy should be reviewed after five years with alendronate, risedronate and ibandronate, and after three years if on zoledronate. Continuation beyond this can be recommended for certain patients – namely anyone over 75 years of age, with a history of hip or vertebral fracture or one or more fragility fractures during treatment, or on long-term glucocorticoid treatment. There is no evidence for prolonging beyond 10 years. Longer-term management should only occur after specialist input and on a case-by-case basis

Strontium ranelate is generally prescribed long-term, but with regular reviews

Denosumab should not be stopped without specialist review as there is usually a need for a bisphosphonate to be prescribed to counteract the rapid bone loss that can occur.

Draw attention to the patient information leaflet to highlight common side-effects, remembering to explain what “common” means in this context

The more frequently experienced side-effects of OP drugs are listed in Table 1 and patients on oral bisphosphonates should be advised to stop and seek medical advice if they develop symptoms of oesophageal irritation such as dysphagia, new or worsening heartburn, and pain on swallowing or behind the sternum 

Some more common side-effects – mild GI symptoms, aches and pains with bisphos-phonates, nausea and diarrhoea with strontium ranelate – are more likely to occur soon after starting treatment and will usually subside

For all bisphosphonates, patients should report any hip, thigh or groin pain (which could be a sign of an atypical femoral fracture), or ear pain or discharge (due to the risk of osteonecrosis of the external auditory canal)

Bisphosphonates and denosumab increase the risk of osteonecrosis of the jaw, so patients should be advised to report oral symptoms such as dental mobility, pain or swelling, and encouraged to maintain good oral hygiene, have regular dental check-ups and avoid invasive dental procedures if possible

For the same reason of side-effects impacting the jaw, use of tobacco should be warned against 

Strontium ranelate increases the risk of myocardial infarction, so patients should be advised to promptly report any signs of heart or circulatory problems such as angina symptoms, a rise in blood pressure or symptoms of a blood clot. They should also undergo an assessment every six to 12 months for their individual risk factors for cardiovascular disease

Strontium ranelate can cause severe allergic reactions, so patients should seek immediate medical advice if they develop a skin rash.

This question offers an opportunity to highlight how drug interactions with OP medications are possible with a host of other medicines, including OTC products, supplements and alternative remedies (which can often be overlooked), along with several food or drink items

Bisphosphonates may not be absorbed fully if someone is concurrently using a calcium supplement or antacid. Food and drinks other than plain water may also affect bioavailability. Leaving an interval of at least 30 minutes can resolve this issue. Caution is advised with NSAIDs due to the risk of GI irritation

Strontium ranelate has a number of interactions, many of which revolve around absorption issues (e.g. antacids and calcium salts reduce strontium absorption, while the absorption of several antibiotics including tetracyclines and quinolones may be decreased), and an increased risk of thromboembolism (e.g. cytotoxics, tamoxifen, raloxifene)

Denosumab should be used alongside calcium and vitamin D supplementation.

Calcium supplementation has been shown to increase GI side-effects and is linked to other adverse outcomes such as an increased risk of cardiovascular disease, so the recommendation is for OP patients to try and achieve a daily calcium intake of 700-1,200mg through diet

A vitamin D intake of 400IU per day is advised for all adults, but for postmenopausal women and older men at risk of fractures, evidence supports the use of higher doses: 800IU or higher has been shown to protect against fractures and reduce fall risk

Reducing the risk of falls cuts fracture risk, so steps should be taken to improve safety in the home and introduce exercise programmes, both of which may be components of local falls prevention programmes

Other steps to improve bone health include increasing physical activity, stopping smoking, ensuring sufficient protein intake (using nutritional supplements if necessary) and reducing alcohol intake to less than two units
per day.