Bone health after hip fracture; does introducing a 10 day vitamin D loading regime increase use of inpatient intravenous zoledronate?

 Background: Patients who experience a hip fracture have a high re-fracture risk. Prompt initiation of anti-osteoporosis treatment is therefore vital. Oral bisphosphonates are less well tolerated in some older people resulting in poor adherence. A single dose of IV zoledronate however, can be effective for up to 3 years and is shown to reduce fracture rate by 35% (Gregson, Age and Ageing, Vol 51, 2022).

Aim: To increase use of IV zoledronate post hip fracture in Salford Royal Hospital

Local barriers: a trust guideline advising a 7 week vitamin D loading regime means inpatient IV zoledronate post hip fracture is limited. Waiting time for outpatient parental therapy is > 6 months.

Intervention: • A new trust wide guideline was written, approving rapid vitamin D loading over 10 days post fragility fracture to promote IV zoledronate use.

Methods: Retrospective analysis of case notes for 100 patients admitted with hip fracture at baseline (August 2021). Repeat data collection performed post intervention in August 2023 (100 patients) and March 2024 (30 patients). We recorded FRAX recommendation, adherence to new vitamin D regime, bone health plan on discharge, and osteoporosis treatment implemented.

Results: There was an increase in inpatient zoledronate use to 30 % (5% at baseline). Oral bisphosphonate use reduced to 10% (28%). There was 98% adherence to the new rapid vitamin D loading regime.

In cycle 2, 6% of patients did not receive planned IV zoledronate as discharged before vitamin D loading completion. 2% did not receive planned IV zoledronate despite vitamin D loading complete

Conclusions: Rapid vitamin D loading allowed more patients to receive inpatient IV zoledronate post hip fracture. There is scope to increase this further. Future plans include adding ‘date for IV zoledronate’ to the electronic notes template and including bone health in the pre-weekend check list to avoid delay in IV zoledronate administration.