This audit summarizes the current practice of zoledronic acid therapy at NNUH. It found that 73% of patients received zoledronic acid for osteoporosis. Most patients had previously tried other osteoporosis therapies. While most patients received information and supplements, some did not have information fully explained or receive calcium and vitamin D. All patients had creatinine clearance and calcium levels checked. Most were told to drink water before and observed after the infusion, though a few were not. The audit concluded areas of current practice that could be improved.

1. Zoledronic acid Audit Dr R Musa

2. Introduction Zoledronic Acid Highly potent bisphosphonate Developed for therapy of malignant hypercalcaemia Major advantage once yearly IV infusion over 15 mins IV route lowers risk of esophagitis seen with oral bisphosphonate Licensed for postmenopausal osteoporosis

3. Reduce New Clinical Fracture 38% RRR 5% ARR NNT 20 13.9% 8.6%

4. Adverse Events Atrial fibrillation (1.3% with ZA vs 0.5% with placebo) Adverse events more common in treatment group than placebo group: Myalgias around infusion time (3.1 vs 0.9%) Pyrexia around infusion time (6.9 vs 0.9%) No reported cases of osteonecrosis of the jaw

5. Conduct of the Audit The aims of the Audit To evaluate the current practice of Zoledronic acid therapy at NNUH. Methods: The Audit form prepared by Dr R Musa Data collected by the nurses in rheumatology day units The period from (March 2009 to June 2009) 4 months Total of (12 patients) attended for Zolendronic acid infusion 11 patients had the infusion

7. Indication for Aclasta 73 % osteoporosis 3% osteoporosis + Malignancies 3% Paget disease 3% Pathologic fracture

8. which osteoporosis therapy tried IV Pamidronate (3) Alendronic acid (5) Ibandronate Risedronate (1) Actonel (1)

9. Have the information been explained to the patients Have the information been explained to the patient 0 2 4 6 8 Yes (7) patients No (2) patients Do not Know (2) patients

10. Has the patient been given oral calcium & Vitamin D Yes (55%) No (36%) Do not know (3%)

11. Creatinine clearance > 40ml/min 0 2 4 6 8 10 12 11 patients One patient C.C < 35 Not given ZA All patients have their calcium level Checked (100%)

12. 5 patients Not told to drink more water 5 patients Told to drink more water One patient Given tea Has the patient been told to drink glass of water before the infusion

13. Observation for 20 min after the end of infusion 73% (Yes) 27 % (No)

14. YES (91%) NO (9%) Has the patient been informed that one third may develop flu like illness

15. Conclusion 1-make sure the indication for ZA in NNUH is for osteoporosis 2-patient already tried all usual Osteoporotic therapy before referral for ZA 3-information should be explained to patients and given leaflet during clinic time. 4-patients should be given adequate Vit D & Ca supplement before referral for ZA infusion 5-Creatinine clearance and Calcium level should be checked 6-patient should be told to drink adequate water before ZA infusion