11/13/24, 8\:15 PM Guide | Bisphosphonate counselling

Bisphosphonate counselling

Table of contents

Introduction

This guide provides a structured approach bisphosphonate counselling in an OSCE setting. With practice, you will develop
your own style for conveying this information to a patient in a structured and concise manner.

Opening the consultation

Introduce yourself to the patient including your name and role.
Con
Clarify the purpose of the consultation\:
“ T o d a y w e' l l b e d i s c u s s i n g a t y p e o f m e d i c a t i o n c a l l e d a b i s p h o s p h o n a t e .
”
It is important to establish a good rapport and an open line of communication with the patient early in the consultation\:
h a v e a n y q u e s t i o n s a t a n y p o i n t- o r i f s o m e t h i n g i s n o t c l e a r- p l e a s e f e e l f r e e t o i n t e r r u p t a n d a s k m e .
”
“ I f y o u

Ideas, concerns & expectations

A key component of counselling involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE).
Asking about a patient’s ideas, concerns and expectations can allow you to gain insight into how a patient currently perceives
their situation, what they are worried about and what they expect from the consultation. It can sometimes be challenging to use
the ICE structure in a way that sounds natural in your consultation, but we have provided some examples for each of the three
areas below.
Ideas
" D o y o u k n o w a n y t h i n g a b o u t b i s p h o s p h o n a t e s ?"
" D o y o u k n o w w h a t b i s p h o s p h o n a t e s a r e u s e d f o r ?"
Concerns
" I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t' s w o r r y i n g y o u ?"
“ W h a t’ s y o u r n u m b e r o n e c o n c e r n r e g a r d i n g t h e t r e a t m e n t a t t h e m o m e n t ?”
Expectations
“ W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?”
“ W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?”
“ W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?”

Patient history

Although the purpose of this station is to counsel the patient, it is a good idea to gather a quick, focussed history early in the
consultation. For example, bisphosphonates are commonly prescribed after an elderly patient has had a fracture, or a DEXA
1
scan has identi
explain to them why it is important that they take it.
You should also ask if the patient is on any other medications and if they su
you when you are explaining possible side e
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It is helpful to screen for osteoporosis risk factors including smoking, alcohol, steroid use and being post-menopause. Taking
a social history can help highlight what lifestyle advice you can signpost your patient to (e.g. discussing smoking cessation if
they are a smoker).
Tip\: Practice doing this in an OSCE timeframe- introductions, ICE and patient history should take no longer than 2 minutes of
your time.

What are bisphosphonates?

Bisphosphonates are a group of drugs that are used to treat thinning bones. In an OSCE station, the patient will most likely
have been prescribed bisphosphonates for osteoporosis but in practice, they are also sometimes used to treat patients with
bone metastases and Paget's disease. They work by slowing down the process of bone breakdown by osteoclasts, whilst
allowing osteoblasts to continue enhancing bone density.
2
You should use patient-friendly language when explaining this- keep it simple!
Example
" O s t e o p o r o s i s i s a c o n d i t i o n t h a t i n v o l v e s t h i n n i n g o f t h e b o n e s , w h i c h i n c r e a s e s t h e r i s k o f f r a c t u r e s . B i s p h o s p h o n a t e s
w o r k b y p r e v e n t i n g t h e t h i n n i n g o f t h e b o n e s , a l l o w i n g t h e b o n e s t o ga i n s t r e n gt h o v e r t i m e a n d u l t i m a t e l y r e d u c i n g t h e
r i s k o f f u t u r e f r a c t u r e s .
"

How to take bisphosphonates

There are several di
used medication for osteoporosis is alendronic acid, which is taken as an oral tablet once a week. You should advise the
patient to take the tablet on the same day each week (alendronic acid is also available as a daily preparation, but this is not
common practice).
The tablet should be taken with a large glass of water in the morning, at least 30 minutes before the
medicinal product of the day. Advise the patient to sit upright for 30 mins after taking the tablet as alendronic acid can cause
oesophageal irritation, ulceration and in some cases strictures.
2
If the patient misses a tablet, they should take it the morning after remembering. They should not take 2 tablets in one day.
Example
" Y o u s h o u l d t a k e y o u r a l e n d r o n i c a c i d t a b l e t o n c e a w e e k , a n d o n t h e s a m e d a y e a c h w e e k . T h e s e t a b l e t s c a n i r r i t a t e t h e
s t o m a c h a n d g u l l e t , s o t o a v o i d t h i s w e a d v i s e t a k i n g t h e t a b l e t w i t h a l a r ge gl a s s o f w a t e r a n d r e m a i n i n g u p r i g h t f o r 3 0
m i n u t e s a f t e r t a k i n g i t . Y o u s h o u l d t a k e t h e t a b l e t i n t h e m o r n i n g , a t l e a s t 3 0 m i n u t e s b e f o r e t h e
m e d i c i n a l p r o d u c t o f t h e d a y . I f y o u m i s s a t a b l e t , y o u s h o u l d t a k e i t i n t h e m o r n i n g a f t e r r e m e m b e r i n g, b u t y o u s h o u l d n o t
t a k e t w o t a b l e t s i n o n e d a y .
"

Treatment timinings

It will take roughly 6 months for the bisphosphonate to take e2
the medication but stress the importance of continuing the treatment anyway.
Explain to the patient that they will not feel the e
The patient’s GP will review their medication every year but as this is a preventative treatment, they will be prescribed
bisphosphonates long term.
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Example
" I t t a k e s r o u g h l y 6 m o n t h s f o r t h e b i s p h o s p h o n a t e t o s t a r t s t r e n g t h e n i n g y o u r b o n e s . Y o u w i l l m o s t l i k e l y n o t f e e l a n y
d i
m e d i c a t i o n a n d y o u r G P w i l l r e v i e w i t a n n u a l l y .
"

Side e

The main side e
irritation in the gullet which can cause the patient to experience heartburn. Advise the patient that if they begin to experience
heartburn, chest pain or di
take over the counter painkillers, such as ibuprofen, without consulting a doctor
irritation.
Other common side e
side e
Osteonecrosis of the jaw is a rare, but very serious side e
osteonecrosis of the jaw is a chronic condition of the oral cavity resulting in mucosal ulceration and exposure of underlying
necrotic bone, which can then also become infected. Symptoms of this condition include persistent mucosal ulceration, pain
and facial swelling. You should ensure that the patient understands the importance of attending annual dental check-ups and
knows that they should inform their dentist that they are taking a bisphosphonate.
Remember to safety net the patient\:
“ S h o u l d y o u d e v e l o p a n y o f t h e s y m p t o m s w e' v e d i s c u s s e d , p l e a s e d o n' t h e s i t a t e t o s e e k
m e d i c a l r e v i e w . I f s i d e e
”
Example
" A s w i t h a l l m e d i c a t i o n s y o u m a y e x p e r i e n c e s o m e s i d e e
y o u m a y k n o w t h i s a s h e a r t b u r n . T o a v o i d t h i s , y o u s h o u l d t a k e t h e t a b l e t a s w e p r e v i o u s l y d i s c u s s e d . Y o u s h o u l d c o n s u l t
y o u r G P b e f o r e t a k i n g a n y p a i n k i l l e r s s u c h a s i b u p r o f e n . I f y o u h a v e a n y c h e s t p a i n o r d i
c o n t a c t y o u r G P i m m e d i a t e l y . I n t h e
t y p i c a l l y r e s o l v e s o n i t s o w n . A r a r e , b u t v e r y s e r i o u s s i d e e
S y m p t o m s o f t h i s c o n d i t i o n c a n i n c l u d e u l c e r s i n y o u r m o u t h t h a t a r e n' t h e a l i n g, p a i n i n y o u r m o u t h a n d j a w a n d s w e l l i n g
o f y o u r f a c e . I f y o u d e v e l o p a n y o f t h e s e s y m p t o m s , y o u s h o u l d s e e k u r ge n t m e d i c a l r e v i e w . I t' s r e a l l y i m p o r t a n t t h a t y o u
a t t e n d a n n u a l d e n t a l c h e c k u p s , t o i d e n t i f y a n y e a r l y s i gn s o f t h i s d i s e a s e .
"

Lifestyle advice

Bisphosphonates work to improve bone health alongside a healthy lifestyle. You should stress to the patient the importance of
diet and exercise in helping to strengthen their bones.
Explain that they should be aiming to exercise daily. Ideally, this should be a weight-bearing form of exercise, such as
walking, hiking, jogging, or resistance training. The more they use their bones, the stronger they will become.
Advise the patient to include high calcium foods in their diets, such as dairy foods, leafy green vegetables, soya beans, nuts,
or bony 3
You can also suggest prescribing a calcium and vitamin D supplement to assist with their intake.
If the patient is a smoker you should explain that smoking is a risk factor for bone thinning and fracture and provide further
details about local smoking cessation services.
Example
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" T h e r e a r e w a y s i n w h i c h y o u c a n i m p r o v e y o u r b o n e h e a l t h a l o n gs i d e t a k i n g b i s p h o s p h o n a t e s . E x e r c i s e i s v e r y i m p o r t a n t
f o r s t r e n g t h e n i n g b o n e s a n d t h e r e f o r e y o u s h o u l d a i m t o e x e r c i s e d a i l y . W a l k i n g , j o gg i n g a n d r e s i s t a n c e t r a i n i n g a r e t h e
m o s t b e n e
b o n e s w i l l b e c o m e . A d i e t w i t h a d e q u a t e a m o u n t s o f c a l c i u m a l s o p l a y s a s i gn i
f o o d s w h i c h c o n t a i n c a l c i u m i n c l u d e m i l k , l e a f y gr e e n s , s o y a b e a n s , n u t s a n d b o n y
w i t h e a t i n g e n o u g h c a l c i u m-r i c h f o o d w e c a n a l s o c o n s i d e r p r e s c r i b i n g a c a l c i u m s u p p l e m e n t .
"

Closing the consultation

It is good practice to summarise the key points at the end of the consultation to check the patient's understanding and
address any remaining questions.
You should also provide the patient with a lea
they can read this in their own time once at home.
Make sure to thank the patient for their time at the end of the consultation.
Example
" T o s u m m a r i s e , t h i s b i s p h o s p h o n a t e m e d i c a t i o n w i l l h e l p t o s t r e n gt h e n y o u r b o n e s a n d r e d u c e t h e r i s k o f f r a c t u r e s i f y o u
t a k e i t r e g u l a r l y . Y o u' l l n e e d t o t a k e t h e m e d i c a t i o n o n c e a w e e k w i t h a l a r g e gl a s s o f w a t e r a n d a v o i d a n y f o o d o r d r i n k s
o t h e r t h a n w a t e r f o r 2 h o u r s a f t e r t a k i n g i t . B i s p h o s p h o n a t e s d o h a v e s e v e r a l p o t e n t i a l s i d e e
t h e g u l l e t a n d i n r a r e c a s e s , d a m a g e t o t h e b o n e o f t h e j a w . I f y o u h a v e a n y c o n c e r n i n g s y m p t o m s , l i k e t h o s e w e' v e
d i s c u s s e d , y o u s h o u l d s e e k a n u r g e n t m e d i c a l r e v i e w w i t h y o u r G P . E x e r c i s e a n d a h i g h c a l c i u m d i e t w i l l h e l p t o
s t r e n g t h e n y o u r b o n e s a l o n g s i d e b i s p h o s p h a t e t h e r a p y . I a p p r e c i a t e t h a t t h i s i s a l o t o f i n f o r m a t i o n t h a t I h a v e gi v e n y o u i n
o n e c o n s u l t a t i o n , b u t I d o h a v e a l e a
f o r m e ?"

References

1. Osteoporosis Management. Published in 2016. Available from\: [LINK].
2. Paitnet.info. Bisphosphonates. Published in 2018. Available from\: [LINK].
3. NHS Vitamins and minerals\: Calcium. Published in 2017. Available from\: [LINK].
Source\: geekymedics.com
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