This guide provides a structured approach bisphosphonatecounselling 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.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Clarify the purpose of the consultation: “Today we’ll be discussing a type of medication called a bisphosphonate.”
It is important to establish a good rapport and an open line of communication with the patient early in the consultation: “If you have any questions at any point- or if something is not clear- please feel free to interrupt and ask me.”
Patient’s ideas concerns and 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.
“Do you know anything about bisphosphonates?”
“Do you know what bisphosphonates are used for?”
“Is there anything, in particular, that’s worrying you?”
“What’s your number one concern regarding the treatment at the moment?”
“What were you hoping I’d be able to do for you today?”
“What would ideally need to happen for you to feel today’s consultation was a success?”
“What do you think might be the best plan of action?”
Although the purpose of this station is to counsel the patient, it is a good idea to gather a quick, focussedhistory early in the consultation. For example, bisphosphonates are commonly prescribed after an elderly patient has had a fracture, or a DEXAscan has identified that they have osteoporosis.1 Knowing why they have been started on the medication will help you to 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 suffer from gastricreflux or heartburn. This will help you when you are explaining possible sideeffects.
It is helpful to screen for osteoporosis risk factors including smoking, alcohol,steroiduse and being post-menopause. Taking a socialhistory can help highlight what lifestyleadvice 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 and how do they work?
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 bonemetastases and Paget’sdisease. They work by slowing down the process of bonebreakdown by osteoclasts, whilst allowing osteoblasts to continue enhancingbonedensity.2
You should use patient-friendly language when explaining this- keep it simple!
“Osteoporosis is a condition that involves thinning of the bones, which increases the risk of fractures. Bisphosphonates work by preventing the thinning of the bones, allowing the bones to gain strength over time and ultimately reducing the risk of future fractures.“
How to take bisphosphonates
There are several different types of bisphosphonates and methods of drug delivery (e.g. oral, intravenous). The most commonly 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, and the patient should not consume any food or drink, other than water, for 2 hours after taking it. 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 as soon as they remember. They should not take 2 tablets in one day.
“You should take your alendronic acid tablet once a week, and on the same day each week. These tablets can irritate the stomach and gullet, so to avoid this we advise taking the tablet with a large glass of water and remaining upright for 30 minutes after taking it. You should also avoid eating or drinking anything for up to 2 hours after taking the tablet. If you miss a tablet you should take it as soon as you remember, but you should not take two tablets in one day.”
It will take roughly 6 months for the bisphosphonate to take effect.2 Explain to the patient that they will not feel the effects of the medication but stress the importance of continuing the treatment anyway.
The patient’s GP will review their medication every year but as this is a preventative treatment, they will be prescribed bisphosphonates long term.
“It takes roughly 6 months for the bisphosphonate to start strengthening your bones. You will most likely not feel any different in yourself, but it is important to keep taking the medication to keep your bones strong. This will be a long term medication and your GP will review it annually.”
The main side effect to mention, for bisphosphonates, is oesophageal irritation. Explain to the patient that the tablet can cause 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 difficulty swallowing they should tell their GP immediately. You may also wish to advise them to not take over the counter painkillers, such as ibuprofen, without consulting a doctor first, as this can worsen the oesophageal irritation.
Other common side effects to also mention are abdominal pain, nausea, gastrointestinalupset and joint/muscle pain. These side effects typically occur in the first month of treatment and usually resolve spontaneously.
Osteonecrosis of the jaw is a rare, but very serious side effect specific to bisphosphonates. Bisphosphonate-related 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: “Should you develop any of the symptoms we’ve discussed, please don’t hesitate to seek medical review. If side effects are persistent we can discuss switching to an alternative medication.”
“As with all medications you may experience some side effects. Bisphosphonates can cause some irritation in the gullet- you may know this as heartburn. To avoid this, you should take the tablet as we previously discussed. You should consult your GP before taking any painkillers such as ibuprofen. If you have any chest pain or difficulty swallowing you should contact your GP immediately. In the first month, you may experience some abdominal upset and muscle pain, but this typically resolves on its own. A rare, but very serious side effect of bisphosphonates is osteonecrosis of the jaw. Symptoms of this condition can include ulcers in your mouth that aren’t healing, pain in your mouth and jaw and swelling of your face. If you develop any of these symptoms, you should seek urgent medical review. It’s really important that you attend annual dental checkups, to identify any early signs of this disease.”
Bisphosphonates work to improve bone health alongside a healthylifestyle. 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 resistancetraining. The more they use their bones, the stronger they will become.
Advise the patient to include highcalcium foods in their diets, such as dairyfoods, leafy greenvegetables, soya beans, nuts, or bony fish.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.
“There are ways in which you can improve your bone health alongside taking bisphosphonates. Exercise is very important for strengthening bones and therefore you should aim to exercise daily. Walking, jogging and resistance training are the most beneficial forms of exercise for bone health and the more that you do these forms of exercise, the strong your bones will become. A diet with adequate amounts of calcium also plays a significant role in bone health. Examples of foods which contain calcium include milk, leafy greens, soya beans, nuts and bony fish. If you think you might struggle with eating enough calcium-rich food we can also consider prescribing a calcium supplement.”
Closing the consultation
It is good practice to summarise the keypoints 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 leaflet about bisphosphonates (or direct them to the relevant NHS web page), so 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.
“To summarise, this bisphosphonate medication will help to strengthen your bones and reduce the risk of fractures if you take it regularly. You’ll need to take the medication once a week with a large glass of water and avoid any food or drinks other than water for 2 hours after taking it. Bisphosphonates do have several potential side effects, including irritation of the gullet and in rare cases, damage to the bone of the jaw. If you have any concerning symptoms, like those we’ve discussed, you should seek an urgent medical review with your GP. Exercise and a high calcium diet will help to strengthen your bones alongside bisphosphate therapy. I appreciate that this is a lot of information that I have given you in one consultation, but I do have a leaflet for you to take home that summarises the key points. Do you have any questions for me?”
Osteoporosis Management. Published in 2016. Available from: [LINK].
Paitnet.info. Bisphosphonates. Published in 2018. Available from: [LINK].
NHS Vitamins and minerals: Calcium. Published in 2017. Available from: [LINK].