Abstract
Introduction
Fracture prevention is a key component in the care of frail patients who fall. Patients that have already fallen and suffered a fractured neck of femur are highly likely to fall again, and have proven themselves high risk for fracture. Bone protection is a priority, and recent guidelines recommend IV Bisphosphonates as an appropriate 1st line drug. Vitamin D level should be 50 or above before this is given.
Method: I audited the notes of 41 patients age 60 years or over who were admitted in 2022 with a fractured neck of femur. I reviewed their admission Vitamin D level, and whether they required loading with Vitamin D before IV Bisphosphonates could be given. I reviewed the loading regime used, and how many of the patients had received bone protection medication, either as an inpatient or post-discharge. I liaised with 3 other neighbouring trusts to find out their current Vitamin D loading regimens to compare to our own.
Results: The audit identified that 54% of those patients required Vitamin D loading before they could be given IV Bisphosphonates. 36% of those never had their loading regime prescribed, and of those that did all were prescribed a 7 week long regime. 1 patient was already receiving IV Bisphosphonates prior to admission, and continued on those. 4 Patients were prescribed PO Bisphosphonates. 4 patients were Fast-Track or EOL. 7 patients had low CrCl preventing use of bisphosphonates. Of those that remained, none got inpatient treatment. I identified that the long loading regime was proving a barrier, and so drafted a new rapid loading guideline, similar to the practice of nearby trusts. Re-audit to assess the impact of this will be performed in July & August 2023 with results presented at conference
Comments
Rapid loading in the community
I wish we could use rapid loading of Vitamin D in the community to improve compliance and start oral bisphosphonate treatment earlier. Do you think this is possible? Or is correction of Vitamin D prior to oral bisphosphonate use less of an issue?
Hi - Thanks for your question - if we start oral bisphosphonates in hospital we don't wait until we finish Vit D loading, we do it concurrently. We only wait until after loading if we are going to use IV bisphosphonates. So in the community you should be able to start PO bisphosphonates without delay. If rapid loading would improve compliance, which I imagine it would, then that is a good reason in itself to prescribe the rapid loading regime, regardless of the bisphosphonates. Is there a reason why you cant give a 5 day course instead of a 7 week course? The cost must be the same as the amount of tablets needed will be overall the same.
HI Laura, thank you. It is not part of the current primary care Vitamin D guideline but it would be great if it was. It is currently under review so perhaps this may change. Many thanks for your reply.