Reality and Recommendation: Comparison between Current Practice Patterns in a Single Center in Taiwan and the ACR 2010 Recommendations for Glucocorticoid-induced Osteoporosis Treatment among Elderly Patients with Systemic lupus Erythematosus, Polymyositis, and Dermatomyositis

Abstract

Objectives: To compare current practice patterns with the American College of Rheumatology (ACR) 2010 recommendations for prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) for patients over 65 with systemic lupus erythematosus (SLE), polymyositis (PM), or dermatomyositis (DM). Methods: Thirty-eight patients aged above 65 as of October 2009 were included in our study. We retrospectively collected clinical data from electronic medical records and stratified patients into high-, medium-, and low-risk groups based on Fracture Risk Assessment (FRAX) score, history of prior fragility fracture, and bone mineral density, according to the new ACR recommendations. Using the Taiwan version of the FRAX tool, we created a diagram that can serve as a quick reference for corresponding risk stratification in patients in Taiwan receiving corticosteroids. We then identified corresponding treatment choices according to the ACR recommendation and recorded the dose and duration of corticosteroid administration from October 2009 to September 2010. We compared actual prescribing practice to the recommended practice. Multiple variable logistic regression was performed to identify factors that affected adherence to recommendations. Results: Out of 38 patients who fulfilled the inclusion criteria, 31.6% were classified as low risk, 26.3% as medium risk, and 42.1% as high risk. Although pharmacologic interventions for the prevention and treatment of GIOP were recommended for 89.5% overall, and for 66.7%, 100%, and 100% in the low-, medium-, and high-risk groups, respectively, only 14 of the 38 patients (36.8%) in our study received any kind of bisphosphonate or teriparatide to treat or prevent osteoporosis. Specifically, among the 34 patients in our study who met the ACR recommendations to receive pharmacologic interventions, only 13 (38.2%) received antiresorptive medications or teriparatide according to the recommendations, including 1 patient out of 8 (12.5%) in the low-risk group, 3 patients out of 10 (30.0%) in the medium-risk group, and 9 patients out of 16 (56.3%) in the high-risk group. The multivariate logistic regression model showed that past history of osteoporotic fracture was associated with prescription of bisphosphonates or teriparatide (odds ratio = 47.00; 95% confidence interval =1.07 - 2063.68; p=0.046). Conclusion: Much discrepancy exists between the ACR 2010 recommendations and current practices for prevention and treatment of GIOP in patients over 65 who are diagnosed with SLE, PM, or DM. More efforts against GIOP should be made.