An Audit on Timing of Zoledronic Acid/Denosumab Initiation After Fragility Fractures in Older Adults

Abstract Content :

Introduction

Fragility fractures are common in older adults and carry a high risk of refracture and mortality. Evidence shows that intravenous zoledronic acid can reduce refracture risk by up to one-third, with early initiation proven safe. Yet, real-world practice is often delayed by factors such as vitamin D deficiency, frailty, and system-level gaps. This audit assessed current practice at our centre and evaluated improvements after service changes.

Method

A retrospective audit was conducted at Heartlands Hospital. Patients aged ≥60 years admitted with fragility fractures were included: Cycle 1 (Jan–Mar 2023) and Cycle 2 (Jan–Mar 2025). Data were extracted from electronic records, capturing demographics, vitamin D assessment and supplementation, renal function, and timing of zoledronic acid/denosumab initiation.

Results

Cycle 1 included 316 patients; Cycle 2 included 305. Vitamin D assessment improved from 90.5% (Cycle 1) to 92.5% (Cycle 2). Supplementation on admission rose from 61.5% to 65.9%, with an additional 24.9% started in primary care. More patients received bone-protective therapy in Cycle 2, though initiation remained delayed by prolonged vitamin D loading and follow-up barriers. Contributing factors included advanced frailty, end-of-life care, and incomplete clinic pathways. Key practice changes proposed were rapid vitamin D loading, earlier intravenous therapy (1 week post-op), and improved communication of bone health plans with primary care.

Conclusion

This audit demonstrates progress in vitamin D management and uptake of secondary fracture prevention therapy, but also exposes ongoing delays in timely initiation of zoledronic acid/denosumab. Embedding rapid vitamin D protocols and standardizing early treatment could close this gap, improving outcomes and reducing future fracture risk in frail older adults. A re-audit will measure the impact of these changes.

Key Learning Points:

1. Early initiation of intravenous zoledronic acid after fragility fractures is safe and reduces refracture risk.
2. Vitamin D deficiency remains a key barrier to timely osteoporosis treatment.
3. Service changes—rapid vitamin D loading and standardized early initiation—can improve secondary prevention in older patients.