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“The main take home message is to pay attention to the prevention and treatment of GIOP while prescribing steroids to the patients because the side effects is steroids are not benign," Shikha Singla, MD, said.
Fully comprehensive assessments for glucose induced osteoporosis are rarely conducted in patients prescribed high dose glucocorticoids as recommended by the American College of Rheumatology guidelines, according to the results of an evaluation of practices in a clinic in Wisconsin presented by investigators at the annual meeting of the American College of Rheumatology.
The ACR guidelines for the prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) recommend optimization of calcium and vitamin D intake and initiation of oral bisphosphonates based on age, fracture risk, and GC dose. In all adults and children, an initial clinical fracture risk assessment should be performed within 6 months of the initiation of long-term glucocorticoid treatment. In addition, absolute fracture risk should be estimated using FRAX in adults aged >40 years within 6 months of the initiation of glucocorticoid treatment.
Investigators conducted a retrospective study evaluating 61 patients aged 40 to 90 year on whether rheumatology patients prescribed chronic high-dose prednisone by Froedtert Hospital Rheumatology Clinic providers between January 1, 2017, and December 31, 2017, actually underwent such comprehensive assessment.
They found that a comprehensive GIOP assessment including calcium, vitamin D, DXA imaging, and FRAX calculation was completed in just 7% of the patients. None of the factors were assessed in 21% of patients, only 1 in 39%, 2 in 16% had 2 factors assessed, and 3 in another 16%.
Shikha Singla, MD, assistant professor at the Medical College of Wisconsin, said she was surprised by the findings. “I used to think that we (rheumatologists) complied to all ACR guidelines for prevention and treatment of GIOP.”
Closer analysis of the findings revealed that DXA and FRAX were the least likely of the 4 assessment components to be completed; FRAX calculations were completed for just 11% of patients and only 26% of patients received DXA imaging.
The robustness of the assessments was higher for patients prescribed very high dose glucocorticoids, aged over 50 and those who saw the clinic pharmacist, will these groups of patients receiving more of the individual assessment components.
A third of patients aged over 50 underwent DXA imaging, compared with no patients under the age of 50; 77% of patients receiving very high dose prednisolone received calcium assessment and vitamin D level assessment compared with 44% and 41% for those on lower doses; and FRAX was calculated for 42% of patients who met with the rheumatology clinic pharmacist with 25% received a comprehensive GIOP assessment comparing with 4% and 2% respectively for patients not meet with the pharmacist.
Patients who received a baseline diagnosis of osteoporosis were more likely to receive calcium supplementation during the follow up period than patients who had not (79% vs 32%, p=0.004).
During the follow-up period, 8% of patients developed a new fracture, 8.5% were diagnosed with osteopenia or osteoporosis, and 14.9% were started on a new osteoporosis medication.
Although the results were only representative of 1 center, Singla told Rheumatology Network that they indicated rheumatologists need to pay more attention to GIOP assessment, and that pharmacists can support them in doing this
“Rheumatologists need to spend a few extra minutes to address the issue of GIOP when they prescribe steroids,” she said. “I think pharmacists can be very helpful by checking the medication list and reminding the physicians about prescribing appropriate therapy.
“The main take home message is to pay attention to the prevention and treatment of GIOP while prescribing steroids to the patients because the side effects is steroids are not benign.”
Stefl A, Singla S, Michaud J, et al. Assessment and treatment of glucocorticoid-induced osteoporosis in a rheumatology clinic. Presented at: American College of Rheumatology Convergence 2020; November 5-9, 2020; Virtual. Accessed November 8, 2020. https://acrabstracts.org/abstract/assessment-and-treatment-of-glucocorticoid-induced-osteoporosis-in-a-rheumatology-clinic/