Title of Project: NHS Dumfries & Galloway Review of bisphosphonate prescribing May 2014 1 Reason for the review The aim of this audit is to review patients prescribed a bisphosphonate for the prophylaxis or treatment of osteoporosis. Osteoporosis is a disease characterised by low bone mass and structural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. Osteoporosis leads to nearly 9 million fractures annually worldwide 1, and over 300,000 patients present with fragility fractures to hospitals in the UK each year 2. There is well documented evidence for the efficacy of bisphosphonates, however there is also uncertainty about the optimal duration of treatment and reports of rare but serious adverse effects such as osteo-necrosis of the jaw and atypical femoral fractures. Because of these concerns of side-effects resulting from long-term therapy, many physicians prescribe these drugs for a finite period of time. Reassessment of fracture risk at the end of this treatment period is important, since some people remain at high risk of fracture and require continued treatment whereas others may be able to stop. To facilitate such review NHS Dumfries and Galloway (D&G) has produced guidance for the management of patients at increased risk of fracture in D&G 3 which is attached as Appendix 1 and 2. It is advised that patients are reassessed after at least 5 years of treatment and after 8-10 years. This comprehensive reassessment includes consideration of age, frailty, fracture history, steroid therapy and DEXA results to ascertain if treatment should be continued, stopped or a drug holiday appropriate. A bone health review is also recommended for all patients on long term treatment. The Royal College of Physicians Glucocorticoid-induced osteoporosis: guidelines for prevention and treatment 4 provide guidance for reviewing patients prescribed bisphosphonates while on steroid therapy. This group of patients should also be reviewed as per Appendix 3. 2 Inclusion Criteria All patients prescribed a bisphosphonate for prophylaxis or treatment of osteoporosis for 5 years or 8-10 years or more All patients prescribed a bisphosphonate for prevention and treatment of glucocorticoid-induced osteoporosis 3 Exclusion Criteria Patients with terminal cancer or receiving palliative care Patients managed by Secondary Care Patients deemed inappropriate for review by GP
4 Preparation and planning Implementation of the audit in selected GP practices by the Prescribing Support Team is as follows: Protocol to be discussed with all GPs in the Practice to ensure that agreement to proceed is reached Computer search of all patients according to the inclusion criteria Review of patients medical notes and repeat prescribing records: Patients prescribed for more than 5 years to be reviewed as per Appendix 1 Patients prescribed for 8-10 years or more to be reviewed as per Appendix 2 Patients on oral steroids to be reviewed as per Appendix 3 List of eligible patients to be reviewed by GP(s) If the review results in requiring more than 5 DEXA scans from any one practice please contact Dr Anne Drever before making referrals via SCI gateway Letters or phone calls to eligible patients and medication altered as discussed with the GP. 5 Action/ Best Practice Practice administration staff to be made aware of the review References: 1. Johnell O, Kanis JA (2006) An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporosis International 17: 1726-33 2. British Orthopaedic Association (2007) The care of patients with fragility fracture 3. Dr Anne Drever (2013) Management of patients at increased risk of fracture in Dumfries and Galloway 4. Bone and Tooth Society, National Osteoporosis Society, Royal College of Physicians (2002) Glucocorticoid-induced osteoporosis: guidelines for prevention and treatment. London: RCP Review to be undertaken by: GP Authorisation: Date:
Data Collection Form Collection by: Date: Practice: Full Name Patient Details Medication Details Review Age Usual GP Name, strength, formulation Dose Qty Date drug added Most recent issue Indication Treatment duration Bone health review? Fracture history? Oral steroid? Dexa in last 3-5 yrs? Comments/Review outcome
Appendix1
Appendix 2
Appendix 3