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Randomized Controlled Trial
. 2023 Sep 1;52(9):afad172.
doi: 10.1093/ageing/afad172.

Call to action: a five nations consensus on the use of intravenous zoledronate after hip fracture

Antony Johansen  1   2 , Opinder Sahota  3 , Frances Dockery  4 , Alison J Black  5 , Alasdair M J MacLullich  6   7 , M Kassim Javaid  2   8 , Emer Ahern  9   10   11 , Celia L Gregson  12   13
Affiliations
Randomized Controlled Trial

Call to action: a five nations consensus on the use of intravenous zoledronate after hip fracture

Antony Johansen et al. Age Ageing. .

Erratum in

Abstract

Currently in the UK and Ireland, after a hip fracture most patients do not receive bone protection medication to reduce the risk of refracture. Yet randomised controlled trial data specifically examining patients with hip fracture have shown that intravenous zoledronate reduces refracture risk by a third. Despite this evidence, use of intravenous zoledronate is highly variable following a hip fracture; many hospitals are providing this treatment, whilst most are currently not. A range of clinical uncertainties, doubts over the evidence base and practical concerns are cited as reasons. This paper discusses these concerns and provides guidance from expert consensus, aiming to assist orthogeriatricians, pharmacists and health services managers establish local protocols to deliver this highly clinically and cost-effective treatment to patients before they leave hospital, in order to reduce costly re-fractures in this frail population.

Keywords: hip fracture; older people; osteoporosis; secondary prevention; zoledronate.

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Conflict of interest statement

All eight authors have completed and submitted the declaration of interest forms used by NICE for its advisory committees. These identify that M.K.J. is an advisory group member, that O.S. and M.K.J. have received speaker fees, that M.K.J. has received institutional grant funding, and consultancy fees and that A.J.B. and M.K.J. have received support for conference registration, accommodation and travel from various drug companies. However, none of these companies are the manufacturers of Aclasta or of generic forms of zoledronate. The authors’ other declarations, of non-financial, professional or personal interest reflect their voluntary roles in the national and international organisation that are described in the Methodology section; including A.J., A.M. and E.A.’s roles as leads of the hip fracture audits for the five nations of the British Isles.

Figures

Figure 1
Figure 1
NHFD data on variation in bone treatments for patients discharged following presentation with a hip fracture to each of the 170 hospitals in England, Wales and Northern Ireland in 2022.
Figure 2
Figure 2
Flow diagram of a suggested approach to intravenous zoledronate after hip fracture A to F link to sections in the text, where each step is discussed in more detail: A: Vitamin D status and vitamin D loading regimes B: Renal function and the safety, dose, and speed of zoledronate infusions C: Dental issues and low risk of osteonecrosis of the jaw D: Timing of infusion, need to wait 2 weeks and risk of non-union E: How big a dose of IV Zol is needed? F: How often does IV Zol need to be given?
See this image and copyright information in PMC

Comment in

References

    1. Gregson CL, Compston JE. New national osteoporosis guidance—implications for geriatricians. Age Ageing 2022; 51:1–6. 10.1093/ageing/afac044. - DOI - PMC - PubMed
    1. Royal College of Physicians . 15 years of quality improvement: the 2023 National Hip Fracture Database report on 2022. London: RCP, 2023.
    1. Gregson C, Armstrong D, Bowden J et al. UK clinical guideline for the prevention and treatment of osteoporosis. Archives of Osteoporosis 2022; 17: 58. 10.1007/s11657-022-01061-5. - DOI - PMC - PubMed
    1. The National Osteoporosis Guideline Group. NOGG . Clinical guideline for the prevention and treatment of osteoporosis. 2021; 24–8. www.nogg.org.uk.
    1. Scottish Standards of Care for Hip Fracture , 2023. www.shfa.scot.nhs.uk (March 2023, date last accessed).

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