Yood RA, Harrold LR, Fish L, et al. Prevention of glucocorticoid-induced osteoporosis: experience in a managed care setting.

Abstract

Yood RA, Harrold LR, Fish L, et al. Prevention of glucocorticoid-induced osteoporosis: experience in a managed care setting. Arch Intern Med 2001;161:1322–7. In recent years it has become apparent that even low-dose glucocorticoid management may result in bone loss. Despite information that glucocorticoid-induced osteoporosis may be prevented using calcium, vitamin D, and bisphosphonates, many patients do not receive prophylaxis. Yood et al. analyzed osteoporosis prevention in 224 patients who were dispensed at least one prescription of oral glucocorticoid quarterly over the course of a year and who had confirmation of glucocorticoid use in the medical record. Automated databases were used to ascertain information about glucocorticoid prescriptions and prescriptions for prophylactic medication. The mean glucocorticoid dose was 8.9 ± 7.3 mg of prednisone or equivalent. Only 62% of the patients receiving glucocorticoids during the study year had any osteoporosis prophylaxis or a diagnostic intervention documented. This rate was highest among rheumatologists (90%), followed by pulmonologists (55%), internists (48%), and “other specialties” (46%). Only 31% of patients had a bone mineral density study, 40% had calcium supplementation, and 37% vitamin D supplementation. Women were more likely than men to have received education on the need for calcium and vitamin D and were also more likely to have bone-mineral density testing. There are several weaknesses in the study, most of which were recognized by the authors. They did not rely on recorded lists of medication use, but on a database of prescription use at the organization's pharmacies. Physicians may not reliably document use of nonprescription medications, so the results may underestimate calcium and vitamin D use. The mean daily dose of glucocorticoid was calculated but not the pattern in which it was taken (intermittently versus continuously). The authors conclude that many patients are not receiving prevention or management of glucocorticoid-induced osteoporosis, despite publication of guidelines by the American College of Rheumatology. Explanations include a lack of knowledge about the frequency of glucocorticoid-induced osteoporotic fractures, lack of awareness of the existence and effectiveness of prophylactic therapy, and possibly a belief among physicians that there is a safe dose of glucocorticoids. In addition, fragmentation of care among several specialists with no primary care physician may also be a contributing factor.