Screening is Lax in Glucocorticoid-Induced Osteoporosis

Glucocorticoid use in patients has long been associated with osteoporosis, but new studies show that some patients are still not being screened or treated for glucocorticoid-induced osteoporosis (GIOP).

In a recent study, published in the July 7 issue of RMD Open, French researchers write that GIOP management is inadequate, particularly among primary care physicians who prescribe glucocorticoids more frequently than other physicians.

This finding is particularly important because .5 – 1.2% of adults in the United States and United Kingdom are on long-term glucocorticoid therapy. Even at low dosages, glucocorticoids have been associated with increased risk of fractures. Glucocorticoids decreases bone formation and increases bone resorption and within three months can lead to bone fragility.

Led by Pierre Lafforgue, Hopital Sainte-Marguerite, France, researchers culled a national public health insurance database finding that of 32,812 patients (44 percent male, mean age 58 years) were prescribed at least 7.5 mg of prednisone per day for at least 90 days from 2009-2011 and 14,205 patients (43%) “met our definition of incident cases.” Of 14,205 cases, 6,311 (44%) were males and 7,894 (55%) were females, including 4,377 (31%) females older than 55 years old. The average glucocorticoid use was 11 mg/day of prednisone equivalent for an average of 206 days. [[{"type":"media","view_mode":"media_crop","fid":"50086","attributes":{"alt":"©Lightspring/Shutterstock.com","class":"media-image media-image-right","id":"media_crop_3802932257625","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6092","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"©Lightspring/Shutterstock.com","typeof":"foaf:Image"}}]]

"The bone loss induced by glucocorticoids occurs early and at a fast pace, being significant within 6 months. Consequently, an evaluation of bone risk and the implementation of prophylactic measures should take place at, or shortly after, the first prescription of glucocorticoid therapy," the authors wrote.

The majority of first-time prescriptions, 55%, were written by primary care physicians. Rheumatologists wrote 5%, pulmonologists 2%, gastroenterologists 2% and internists 1% (the prescriber’s specialty was unknown in 23% of cases). Patients were prescribed glucocorticoids for rheumatoid arthritis (20%), autoimmune disease such as systemic lupus erythematosus, polyarteritis nodosa or Sjogren’s syndrome (13%); chronic respiratory failure (13%), asthma (10%) or chronic inflammatory bowel disease (8%).

In patients using glucocorticoids, 18% used calcium and/or vitamin D, and 12% used bisophosphonates. Eight percent had bone mass measurement performed. That compared with only 3% who underwent bone mass measurement and 3% that used bisophosphonate therapy in a control population.

Here in the U.S., the American College of Rheumatology recommends using the smallest dose of glucocorticoid for the shortest duration possible as an important strategy to minimize osteoporosis risk. “Since there may be no dose of glucocorticoids that does not accelerate bone loss or increase fracture risk, recommendations for counseling and assessment are extended to all doses of glucocorticoids used or expected to be used for at least three months,” according to the ACR’s updated 2010 recommendations.

Additionally, a study presented at the American College of Rheumatology annual meeting in 2015, showed that 53% of patients treated at a New York Hospital were not appropriately screened or treated for glucocorticoid-induced osteoporosis. Younger patients and male patients were not screened, and new studies show that they too are at higher risk of developing osteoporosis. This study was conducted with rheumatologists, which suggests that this group also underutilizes osteoporosis screening and preventative treatment measures. Better education regarding the screening and treatment of glucocorticoid-induced osteoporosis for both primary care physicians and rheumatologists may be helpful, the authors wrote.

References:

1. Trijau S, de Lamotte G, Pradel V, et al. “Osteoporosis prevention among chronic glucocorticoid users: results from a public insurance database.” RMD Open 2016;2:e000249. doi:10.1136/rmdopen-20 16-00024.

2. Grossman JM, Gordon R, Ranganath VK, et al. “American College of Rheumatology 2010 Recommendations for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis.” Arthritis Care & Research Vol. 62, No. 11, November 2010, pp 1515–1526. DOI 10.1002/acr.20295.

3. Ogando S, Santana C, Blanco I, et al. “Osteoporosis Screening and Treatment of Rheumatoid Arthritis Patients at a Teaching Institution.” ACR 2015 abstract 380.