Osteoporosis Management after New Initiations of Long Term Systemic Glucocorticoids
Long-term systemic glucocorticoid therapy is the most common cause of secondary osteoporosis, and up to 1% of adults are treated with glucocorticoids each year. Glucocorticoid-induced osteoporosis (GIOP) occurs rapidly (6–12% loss of bone mass within the first year), and the risk of fracture increases within 3 months of starting therapy. The first presentation of GIOP may be a fracture, and as many as 30–50% of patients exposed to glucocorticoids will eventually sustain a fracture. Furthermore, although sustained daily doses of 7.5–10 mg prednisone (or equivalent) commonly lead to bone loss and fractures, doses as low as 2.5 mg prednisolone daily have been reported to increase risk of vertebral and hip fractures. Although GIOP is not entirely preventable, it is certainly ameliorable, and there are several relatively consistent guidelines with evidence-based recommendations that suggest bone mineral density (BMD) testing and prophylactic osteoporosis treatment in most if not all patients starting a course of daily 5–10 mg prednisone for 3 months or longer.
Previous studies that have examined the quality of guideline-concordant GIOP preventive care among patients starting a new course of long-term systemic glucocorticoids have reported a large care-gap with rates of BMD testing or osteoporosis treatment far lower than would be expected for such a common iatrogenic condition. Even randomized trials of interventions to improve GIOP care among repeat glucocorticoid prescribers have achieved testing or treatment rates of only 40– 50%. Previous studies of the GIOP care gap have had limitations that include small sample sizes, inclusion of both incident and prevalent glucocorticoid users simultaneously, biased or nonrepresentative populations, older data (to our knowledge, the most recent published audit was in 2003), and/or an inability to examine longer-term temporal trends.
Therefore, researchers conducted a decade-long population based cohort study in the province of Manitoba, Canada, in all adults newly initiating long-term systemic glucocorticoid therapy. Their objectives were to 1) describe temporal trends in the quality of GIOP preventive care from 1998–2008 and 2) determine the rates and correlates of high-quality GIOP preventive care defined as the composite of either a BMD test or new osteoporosis treatment within 6 months of a new long-term systemic glucocorticoid initiation.
In a large population-based cohort, they found that the quality of GIOP preventive care improved 51% over the decade from 1998–2008, although their study also suggests that these improvements have reached a plateau. In absolute terms, GIOP prevention remains suboptimal because only 25% of those starting long-term glucocorticoids received a BMD test or were treated for osteoporosis within 6 months. Several sociodemographic and clinical characteristics were independently associated with lower rates of BMD testing or osteoporosis treatment, most notably, younger age, male sex, and initiation by general practitioners.
Majumdar SR, Lix LM, Yogendran M, Morin SN, Metge CJ, Leslie WD. Population-Based Trends in Osteoporosis Management after New Initiations of Long-Term Systemic Glucocorticoids (1998-2008). Journal of Clinical Endocrinology & Metabolism. Population-Based Trends in Osteoporosis Management after New Initiations of Long-Term Systemic Glucocorticoids (1998–2008)
Objectives: Our objective was to describe changes in glucocorticoid-induced osteoporosis (GIOP) preventive care from 1998–2008 including rates and correlates of bone mineral density (BMD) testing and osteoporosis treatment in new long-term glucocorticoid initiations.
Methods: A population-based study of adults aged 20 yr or older in Manitoba, Canada, was conducted using linked healthcare databases. Subjects with new long-term (?90 d) systemic glucocorticoid initiations were identified within each fiscal year. High-quality GIOP preventive care was defined by the composite of BMD testing or osteoporosis treatment within 6 months of starting glucocorticoids. For each initiation, we identified sociodemographic and clinical characteristics, prednisone dose equivalents, and prescriber specialty. Multivariable Poisson regression models were used to calculate adjusted incidence rate ratios (aIRR).
Results: We studied 17,736 new long-term glucocorticoid initiations; one third were at least 10 mg prednisone daily, and most (64%) were prescribed by general practitioners. Overall, 6-month rates of BMD testing were 6%, osteoporosis treatment 22%, and the composite of testing or treatment 25%. From 1998–2008, there were modest increases in BMD testing (from 4 to 6%), osteoporosis treatment (from 15 to 24%), and testing or treatment [from 17 to 27%; aIRR = 1.51; 95% confidence interval (CI) = 1.40–1.63]. High-quality GIOP preventive care varied significantly by age (16% for those <50 yr vs. 27% for those ?70 yr; aIRR = 0.57; 95% CI = 0.52–0.63), sex (13% for men vs. 34% for women; aIRR = 0.40; 95% CI = 0.37–0.43), and prescriber (23% general practice vs. 44% rheumatology; aIRR = 0.56; 95% CI = 0.52–0.60).
Conclusions: Quality of GIOP preventive care has improved but remains suboptimal with only one quarter of those starting long-term glucocorticoids receiving BMD testing or osteoporosis treatment. Interventions to improve GIOP prevention, especially targeting younger patients, men, and nonspecialists, are needed.
