Denosumab, raloxifene, teriparatide and calcitonin: nursing considerations

Match each drug to how it changes bone

Most of these drugs slow bone breakdown. Denosumab is a RANK ligand inhibitor given by injection that reduces osteoclast formation and activity. Raloxifene is a selective oestrogen receptor modulator, acting like oestrogen on bone while blocking it in breast tissue. Calcitonin also reduces bone breakdown but is now rarely recommended because it has not been shown to reduce fractures.

Teriparatide works the other way. It is a synthetic form of parathyroid hormone that, given as a daily injection, stimulates new bone formation. The bone gained is lost quickly unless the patient moves on to an antiresorptive drug afterwards. So the question to ask is whether the drug builds bone or slows its removal, and what happens when it stops.

Denosumab: calcium, timing and the risk of stopping

Denosumab can cause serious or life-threatening hypocalcaemia, especially in people with advanced kidney disease or on dialysis. Calcium and vitamin D supplements are usually prescribed. Report numbness or tingling around the mouth or fingers, muscle twitching, cramps or spasms, and check that calcium results requested by the prescriber are reviewed before injections where the protocol asks.

Unlike bisphosphonates, denosumab does not stay in bone. If injections are missed or stopped, bone loss can be rapid and multiple vertebral fractures can follow, so drug holidays are not used and another drug is usually started at discontinuation. Like bisphosphonates, it carries risks of jaw osteonecrosis and atypical femur fracture, so dental review and reporting thigh or groin pain still apply.

Practical teaching for denosumab therefore centres on the calendar. Help the patient record the next injection date, explain why a late dose matters even when they feel well, and make sure a change of clinic or insurer does not create a gap. Serious infections and skin reactions such as rash, itching or blisters are also listed warnings and should be reported.

Raloxifene and calcitonin: clots, stroke and nasal effects

Raloxifene's boxed warning covers venous thromboembolism and fatal stroke risk in women with coronary disease. Teach patients to stop and seek help for calf pain, warmth or swelling, sudden chest pain or breathlessness. The label advises stopping it at least three days before planned surgery and avoiding long periods of immobility, such as long journeys, without moving.

Hot flushes and leg cramps are common raloxifene effects, and it is contraindicated in pregnancy. Calcitonin salmon is a nasal spray used once daily, alternating nostrils. Its common adverse effects are local: runny nose, nosebleeds, crusting or dryness. Because it comes from salmon protein, ask about allergy and report hives or breathing difficulty.

Teriparatide injection teaching

Teriparatide is self-injected subcutaneously into the thigh or abdomen once daily from a multi-dose pen, rotating sites and using a new needle each time. The pen is kept in the fridge and discarded after its labelled use period. Early doses can cause dizziness or fainting on standing, so teach the patient to inject where they can sit or lie down straight away.

Ask the patient to report nausea, vomiting, constipation, low energy or muscle weakness, which can signal high calcium. Teaching should also cover what happens at the end of the course, because the gained bone density fades unless another treatment follows. Confirm the patient knows who will arrange the next medicine before the pens run out.

Worked scenario: a missed denosumab injection

In a hypothetical clinic, a woman on denosumab says she skipped her last injection because she felt fine, and she now has new back pain. Options are reassuring her that the effect lasts for years like a bisphosphonate, booking her for the next routine visit, or reporting the missed dose and new pain promptly.

Prompt reporting is the strongest answer. Denosumab's protection wears off once doses lapse, and new back pain may signal a vertebral fracture. The bisphosphonate comparison is the tempting distractor because both reduce bone breakdown, but they behave differently after stopping. The prescriber decides on imaging and the next drug; the nurse's role is to recognise the risk.

Sources and further reading

MedlinePlus: Denosumab injection. Hypocalcaemia, calcium and vitamin D, jaw osteonecrosis, femur fracture and fracture risk after stopping.

MedlinePlus: Raloxifene. Boxed warning for clots and stroke, stopping before surgery, immobility, hot flushes and pregnancy.

MedlinePlus: Teriparatide injection. Parathyroid hormone action, injection sites, pen use, dizziness with early doses and signs of high calcium.

MSD Manual Professional: Osteoporosis. Denosumab rebound and no drug holiday, raloxifene limitations, transition after anabolic therapy and calcitonin's limited role.