Medications for Joint and Bone Conditions

SECTION 1 | Medications for Joint and Bone Conditions

Chapter 29: Bone Disorders

Overview

  • Focus on medications for the prevention and treatment of osteoporosis and prevention of fractures.

  • Key supplements include calcium and vitamin D.

  • Other medications used include agonists/antagonists, bisphosphonates, and calcitonin.

Medication Classifications

  1. Calcium Supplements

    • Select Prototype Medication: Calcium citrate

      • Other Medications:

      • Calcium carbonate

      • Calcium acetate

      • For IV administration:

        • Calcium chloride

        • Calcium gluconate

Purpose and Pharmacological Action

  • Expected Pharmacological Action:

    • Maintains musculoskeletal, neurologic, and cardiovascular function.

Therapeutic Uses

  • Oral calcium supplements are used for:

    • Clients with hypocalcemia or deficiencies of parathyroid hormone, vitamin D, or dietary calcium.

    • Adolescents, older adults, clients who are postmenopausal, pregnant, or breastfeeding.

    • IV medications for critically low levels of calcium.

    • Oral vitamin D supplements enhance dietary calcium absorption.

    • Calcium and vitamin D supplements with calcitonin or bisphosphonates can reduce osteoporosis risk.

Complications

  • Hypercalcemia:

    • Defined as calcium level greater than 10.5 mg/dL.

    • Findings include:

    • Initially: Tachycardia and elevated blood pressure.

    • Eventually: Bradycardia and hypotension.

    • Symptoms: Muscle weakness, hypotonia, constipation, nausea, vomiting, abdominal pain, lethargy, confusion.

Nursing Actions

  • Monitor blood calcium levels to maintain between 9 and 10.5 mg/dL.

  • Assist with the infusion of 0.9% sodium chloride IV.

  • Medications for hypercalcemia reversal include:

    • IV furosemide

    • Calcium chelators (e.g., plicamycin)

  • Prevent hypercalcemia using bisphosphonates (e.g., alendronate) and oral inorganic phosphates.

Contraindications and Precautions

  • Calcium supplements contraindicated in clients:

    • With hypercalcemia, renal calculi, hypophosphatemia, digoxin toxicity, and ventricular fibrillation.

  • Use cautiously in clients with kidney disease or decreased glomerular function.

Interactions

  • Concurrent Use:

    • Glucocorticoids reduce calcium absorption; administer at least 1 hr apart.

    • Calcium decreases absorption of tetracyclines and thyroid hormone; ensure 1 hr and 4 hr intervals, respectively.

    • Thiazide diuretics may increase hypercalcemia risk; monitor.

Nursing Administration

  • Oral calcium tablets: Chewable for consistent bioavailability.

  • IV infusions: Warm to body temperature before administration.

  • IV bolus at 0.5 to 2 mL/min.

  • Monitor IV sites to prevent extravasation.

Client Education

  • Take calcium supplements 1 hr apart from glucocorticoids and tetracyclines; 4 hr apart from thyroid hormone.

  • Consume with 8 oz glass of water.

Nursing Evaluation of Effectiveness

  • Effectiveness evidenced by calcium levels within expected reference range: 9 to 10.5 mg/dL.

Selective Estrogen Receptor Modulators

  • Select Prototype Medication: Raloxifene

Purpose

  • Expected Pharmacological Action:

    • Acts as endogenous estrogen affecting bone, lipid metabolism, and blood coagulation.

    • Decreases bone resorption, slowing bone loss and preserving bone mineral density.

    • Acts as an antagonist to estrogen on breast and endometrial tissue.

    • Can reduce plasma cholesterol levels.

Therapeutic Uses

  • Used in the prevention and treatment of postmenopausal osteoporosis and to prevent spinal fractures in women.

  • Offers protection against breast cancer.

Complications

  • Increased risk for pulmonary embolism and deep vein thrombosis (DVT).

    • Nursing Actions:

    • Stop prior to scheduled immobilization (surgery, extended bedrest).

    • Monitor for DVT manifestations (e.g., red, swollen extremities).

    • Advise against prolonged inactivity (e.g., during long travel).

Other Considerations

  • Hot Flashes:

    • Client education: Medication can exacerbate this symptom.

    • Contraindications/Precautions:

    • Pregnancy: Raloxifene contraindicated for childbearing potential.

    • Lactation: Raloxifene contraindicated.

    • Teratogenic effects: Notify provider if pregnancy is suspected or planned.

    • Patients with a history or risk for venous thrombosis should not use this medication.

    • Temporary cessation of the medication 72 hrs before immobilization.

Interactions

  • Concurrent use with estrogen hormone therapy is discouraged.

Nursing Administration

  • Administer with or without food once daily.

  • Monitor bone density scans every 12 to 18 months.

Client Education

  • Ensure adequate dietary calcium (dairy) and vitamin D (egg yolks).

  • Engaging in weight-bearing exercises daily (walking 30-40 min).

Nursing Evaluation of Effectiveness

  • Evidence of effectiveness includes increased bone density and absence of fractures.

Bisphosphonates

  • Select Prototype Medication: Alendronate

Other Medications

  1. Ibandronate

  2. Risedronate

  3. For IV infusion: Zoledronate

Purpose

  • Expected Pharmacological Action:

    • Decreases the number and activity of osteoclasts, inhibiting bone resorption.

Therapeutic Uses

  • Prophylaxis and treatment of postmenopausal osteoporosis.

  • Treatment for male clients with osteoporosis.

  • Prophylaxis and treatment of osteoporosis caused by long-term glucocorticoid use.

  • Manage Paget's disease of the bone.

  • Treat hypercalcemia due to malignancy.

Complications

  • Esophagitis and esophageal ulceration (oral formulations).

Nursing Actions

  • Instruct clients to sit upright or ambulate for at least 30 min after taking oral medication.

  • Clients taking ibandronate should remain upright and refrain from eating or drinking for 1 hr post-administration.

Gastrointestinal Disturbances

  • Symptoms include abdominal pain, nausea, diarrhea, constipation.

    • Nursing Actions: Notify provider if gastrointestinal issues hinder adequate intake.

Musculoskeletal Pain

  • Client education: Take a mild analgesic; report persistent pain for alternative prescribing.

Visual Disturbances

  • Symptoms may include blurred vision and eye pain.

    • Nursing Education: Report manifestations to provider and discontinue medication if necessary.

Bisphosphonate-Related Osteonecrosis of the Jaw

  • Especially with IV infusion.

    • Nursing Actions: Consult a dentist before starting treatment and avoid dental work while administering.

Kidney Toxicity with IV Infusion

  • Nursing Actions: Monitor kidney function and hydration.

Atypical Femoral Fractures

  • Nursing Actions: Assess the need for continued treatment after 5 years.

Contraindications/Precautions

  • Warnings:

    • Pregnancy: Alendronate safety not established; use ibandronate only if benefits outweigh risks to the fetus.

    • Lactation: Safety not established; use ibandronate cautiously.

    • Contraindicated for clients with esophageal disorders, serious kidney impairment, or hypocalcemia.

    • Clients unable to remain upright for at least 30 min post-administration are contraindicated.

    • Use cautiously in clients with upper gastrointestinal disorders, infections, or liver impairment.

Interactions

  • Alendronate absorption decreases with the following:

    • Calcium, iron, magnesium supplements, antacids, orange juice, and caffeine.

    • Nursing Actions: Wait at least 2 h after administration for antacids or supplements.

Client Education

  • Take medication first thing in the morning on an empty stomach with 240 mL (8 oz) of water.

  • Avoid calcium-containing foods and other medications within 2 h post-administration.

    • Sit or ambulate for at least 30 min after taking.

Nursing Evaluation of Effectiveness

  • Effectiveness determined by increased bone density and absence of fractures.

Calcitonin

  • Select Prototype Medication: Calcitonin-salmon

Purpose

  • Expected Pharmacological Action:

    • Decreases bone resorption by inhibiting osteoclast activity in osteoporosis.

    • Increases renal calcium excretion by inhibiting tubular resorption.

Therapeutic Uses

  • Treats postmenopausal osteoporosis, moderate to severe Paget's disease, hypercalcemia due to hyperparathyroidism, and cancer complications.

Complications

  • Nausea:

    • Client education: Generally self-limiting.

Administration Route

  • Nasal Route: May cause nasal dryness and irritation.

    • Nursing Actions: Inspect nasal mucosa for ulceration; alternate nostrils daily.

Contraindications/Precautions

  • Warnings:

    • Pregnancy: Calcitonin-salmon contraindicated.

    • Lactation: Calcitonin-salmon contraindicated.

    • Contraindicated in clients allergic to fish protein; perform allergy testing if risk is present.

    • Caution with children and clients with kidney disease.

Interactions

  • Concurrent use with lithium may decrease blood lithium levels; monitor closely.

Nursing Administration

  • Administer IM, subcutaneously, or intranasally.

  • The intranasal route approved only for treating postmenopausal osteoporosis.

Client Education

  • High calcium and vitamin D diet recommended.

  • Rotate injection sites if administering subcutaneously; intranasal spray should alternate nostrils.

Nursing Evaluation of Effectiveness

  • Efficacy indicated by increased bone density and calcium levels within the expected range (9 to 10.5 mg/dL).