Bone Health

If you have osteoporosis or osteopenia, a simple fall can cause a broken bone.

In England and Wales every year at least 347,770 people will break a bone after a fall from standing height or less. This compares with 82,000 heart attacks and 95,200 strokes over the same time period.

Back to Prescribing Guidelines by Clinical Area

Hip fracture nearly always require hospitalisation, is fatal in 20% of cases and permanently disables 50% of those affected and only 30% go on to make a full recovery.

Fracture prevention

Calcium and Vitamin D supplements do not prevent fractures.
Bone sparing agents reduce fractures in people who are high risk e.g previous fracture, osteoporosis, osteopenia, prescribed corticosteroid (>7.5mg prednisolone or equivalent per day for >3 months) or aromatase inhibitor.
DEXA scans are not required before commencing treatment with a bone sparing agent.
Calcium and vitamin D can be prescribed alongside bone sparing agent to mitigate the risk of hypocalcaemia.
People who require a calcium and/or vitamin D dietary supplement and are not prescribed a bone sparing agent are asked to purchase over the counter and should not be prescribed as per NHSE guidance (exceptions e.g. patients post bariatric procedures and malabsorption).
The CQC requires adult social care providers to have systems in place that enable residents to access over the counter products.

NHS Somerset Joint Formulary Bisphosphonates and other drugs affecting bone metabolism

Prescribing Guidelines by Clinical Area

NICE Osteoporosis: risk assessment, treatment, and fragility fracture prevention update due July 2026

Royal College of Physicians Fracture Liaison Service Database

NICE

NOGG

NHS Somerset DEXA scan policy

NHSE Policy guidance: conditions for which over the counter items should not be routinely prescribed in primary care

Policy guidance: conditions for which over the counter items should not be routinely prescribed in primary care

Items with limited evidence of clinical effectiveness

Recommendation

Do not prescribe.

This recommendation applies to:

probiotics
vitamins and minerals, except:
- when the patient has a medically diagnosed deficiency, including for those patients who may have a lifelong or chronic condition, or have undergone surgery that results in malabsorption. Continuing need should however be reviewed on a regular basis. Maintenance or preventative treatment is not an exception
- calcium and vitamin D for osteoporosis (only with bone sparing agent for fracture prevention).
- prescription-only vitamin D analogues such as alfacalcidol
- malnutrition including from alcoholism (see National Institute for Health and Care Excellence guidance)
- patients suitable to receive Healthy Start vitamins, which are available to pregnant and breastfeeding people, people with a child under 1 year old, and children under the age of 4 (note: this is not on prescription but commissioned separately).

CQC: Over the counter medicines and homely remedies

Over the counter medicines and homely remedies

Supporting people to self care

People should be supported to manage their own care. Giving people access to over-the-counter products and enabling them to choose is an issue of equality. You should therefore make adjustments to support all people to access them.

You should have a policy to support people who wish to self care or who need to manage their own care. This should include the necessary safeguards to support a person to get access to over-the-counter products, or to support their carer or relatives to provide them. For example, the policy could include how you protect people who may lack mental capacity to make decisions. Staff must be trained and competent to support a person to self care with over-the-counter products.

It is good practice to discuss health needs and medicines with the person and their family. This could be on admission to the care home or when a home care service is provided. The discussion should also include the use of over-the-counter products.

There should be a clear care plan that includes how to trigger a review. This will make sure that over-the-counter products given are safe and still appropriate. Care plans should include how staff will support people to self care. Staff should consider people’s religious beliefs, dietary preferences, intolerances or allergies, and swallowing difficulties.

A person or their relatives may provide their own over-the-counter products. These are not for general use and must remain the property of that person.

A healthcare professional may recommend a specific product to treat a minor condition that does not require ongoing treatment, which the person, their relatives or care staff can buy. For example, athletes foot cream. You must record verbal or written instructions in the person’s care plan.

All over-the-counter products purchased on behalf of the person or brought into a care setting should be:

checked with an appropriate healthcare professional to make sure they are suitable
in date
stored according to the manufacturer’s guidance
recorded in care plans

Any support provided by care staff to help people use OTC products must be recorded. If care staff are responsible for administration, record this on a medicines administration record in line with policy.

Vitamin D guidance

Vitamin D

From about late March or early April to the end of September, most people should be able to make all the vitamin D they need from sunlight. But between October and early March we do not make enough vitamin D from sunlight.
Vitamin D is also found in a small number of foods.
- Sources include:
- oily fish – such as salmon, sardines, trout, herring or mackerel
- red meat
- egg yolks
- fortified foods – such as some fat spreads and breakfast cereals
- liver (avoid liver if you're pregnant – find out about foods to avoid in pregnancy)
- Another source of vitamin D is dietary supplements.

If dietary vitamin D is required, then patients will need to consider increasing dietary intake or purchase supplement over the counter as this should not be prescribed in primary care as per NHSE guidance (exceptions include patients with malabsorption and post bariatric surgery).

People at risk of vitamin D deficiency

Some people will not make enough vitamin D from sunlight because they have very little or no sunshine exposure.
The Department of Health and Social Care recommends that adults and children over 4 take a daily supplement containing 10 micrograms of vitamin D throughout the year if they:
are not often outdoors – for example, if they're frail or housebound
are in an institution like a care home
usually wear clothes that cover up most of their skin when outdoors

If you have dark skin – for example you have an African, African-Caribbean or south Asian background – you may also not make enough vitamin D from sunlight.

You should consider taking a daily supplement containing 10 micrograms of vitamin D throughout the year.

Royal College of Physicians Fracture Liaison Service Database