Calcium, Bone, and Osteoporosis Medications

calcium glutinate (IV)

key use: rapid correction of severe hypocalcemia
major risks/adverse effects: IV irritation/extravasation risk; caution with digoxin
nursing pearl: give carefully and monitor cardiac status

calcium chloride (IV)

key use: severe hypocalcemia; parenteral calcium replacement
major risks/adverse effects: highly irritating; never IM; extravasation injury
nursing pearl: warm to body temperature and infuse slowly

oral calcium salts (e.g. calcium citrate)

key use: mild hypocalcemia and maintenance therapy
major risks/adverse effects: hypercalcemia with excess dosing; many drug interactions
nursing pearl: separate from tetracyclines, fluoroquinolone, thyroid hormone, bisphosphonates, and phenytoin

cinacalcet (Sensipar)

key use: primary or secondary hyperparathyroidism; hypercalcemia relate to hyperparathyroidism
major risks/adverse effects: nausea, vomiting, diarrhea, hypocalcemia
nursing pearl: suppresses PTH by increasing calcium-sensing receptor sensitivity

vitamin D preparations (ergocalciferol, cholecalciferol, calcitriol, doxercalciferol, paricalcitol)

key use: vitamin D deficiency; calcium/phosphorus homeostasis; selected CKD and hypoparathyroid states
major risks/adverse effects: vitamin D toxicity can cause hypercalcemia, GI symptoms, kidney effects, confusion, dysrhythmias
nursing pearl: essential adjunct when replacing calcium long term

calcitonin-salmon

key use: hypercalcemia, Paget disease, osteoporosis
major risks/adverse effects: can cause nausea and other adverse effects depending on route
nursing pearls: lowers calcium by decreasing bone resorption and increasing renal calcium excretion

bisphosphonates (class)

key use: osteoporosis, Paget disease, hypercalcemia of malignancy, glucocorticoid-induced osteoporosis
major risks/adverse effects: GI irritation, esophagitis, atypical fractures, osteonecrosis of jaw (ONJ), renal concerns depending on agent
nursing pearl: inhibit osteoclast0mediated bone resorption

alendronate (Fosamax)

key use: postmenopausal, male, and glucocorticoid-induced osteoporosis; Paget disease
major risks/ adverse effects: esophageal ulceration, musculoskeletal pain, atypical femoral fracture, ONJ
nursing pearl: take on empty stomach with water; remain upright for at least 30 minutes

risedronate (actonel)

key use: osteoporosis and Paget disease
major risks/adverse effects: arthralgia, diarrhea, headache, rash, nausea, esophagitis, atypical fractures
nursing pearl: same careful oral administration teaching as other oral bisphosphonates

ibandronate (Boniva)

key use: prevention and treatment of postmenopausal osteoporosis
major risks/adverse effects: GI effects, ocular inflammation, atypical fractures, ONJ; renal injury if IV too rapid
nursing pearl: given monthly orally or every 3 months IV

raloxifene (Evista)

key use: osteoporosis; also reduces some breast cancer risk
major risks/adverse effects: thromboembolic events, stroke risk, fetal harm
nursing pearl: avoid in patients with history of DVT/PE

teriparatide (Forteo)

key use: severe osteoporosis; promotes new bone formation
major risks/adverse effects: nausea, headache, back pain, leg cramps, hypercalcemia
nursing pearl: only listed agent here that increases bone formation

denosumab (Prolia, Xgeva)

key use: osteoporosis in high-risk women/men; bone loss with certain cancer therapies; skeletal-related event prevention in bone metastases
major risks/adverse effects: hypocalcemia, serious infections, dermatologic reactions, ONJ
nursing pearl: check calcium and vitamin D status before and during therapy