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Prevention of Glucocorticoid-Induced Osteoporosis
Experience in a Managed Care Setting
Robert A. Yood, MD;
Leslie R. Harrold, MD, MPH;
Leslie Fish, PharmD;
Jackie Cernieux, MPH;
Srinivas Emani, MA;
Elisabeth Conboy, RN, BSN;
Jerry H. Gurwitz, MD
Arch Intern Med. 2001;161:1322-1327.
ABSTRACT
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Background Treatment with glucocorticoids is the leading cause of drug-induced
osteoporosis. Currently available guidelines indicate that patients receiving
long-term glucocorticoid therapy should receive measures to prevent osteoporosis.
Objectives To examine whether patients receiving long-term glucocorticoid therapy
in a managed care setting received preventive therapy or prescribed medications
for osteoporosis and to identify patient and provider characteristics associated
with treatment.
Subjects and Methods A cohort of 224 health plan enrollees 20 years and older who were dispensed
at least 1 oral glucocorticoid prescription per quarter during the period
October 1997 through September 1998 was identified from administrative data.
Medical charts and administrative data were reviewed to determine use of preventive
therapy and prescribed medications for osteoporosis.
Results Of the 224 patients, 62% had at least 1 documented intervention aimed
at osteoporosis prevention (counseling about calcium or vitamin D or weight-bearing
exercise; prescription for estrogen, calcitonin, or bisphosphonate; or a bone
mineral density study). Women were more likely than men to receive intervention
(76% vs 44%; prevalence odds ratio, 4.41; 95% confidence interval, 2.17-9.10).
Patients receiving a mean daily prednisone dose of 10 mg or more or 5 to less
than 10 mg were no more likely to receive intervention than those receiving
5 mg or less prednisone daily. Sixty-two (90%) of 69 patients who were prescribed
glucocorticoid therapy by rheumatologists had at least 1 intervention documented
compared with 29 (48%) of 60 for internists, 26 (55%) of 47 for pulmonologists,
and 22 (46%) of 48 for all other physicians. In a multiple logistic regression
model, including patient age, sex, mean daily glucocorticoid dose, and physician
specialty, women and patients prescribed glucocorticoids by a rheumatologist
were significantly more likely to receive intervention aimed at osteoporosis
prevention.
Conclusions A substantial proportion of patients receiving long-term glucocorticoid
therapy do not receive preventive therapy for osteoporosis. Efforts should
be made to reduce barriers to such treatment and increase the proportion of
patients given preventive therapy.
INTRODUCTION
ALTHOUGH glucocorticoid therapy is used extensively to treat a variety
of diseases, in recent years, it has become apparent that even low-dose glucocorticoid
therapy may result in bone loss.1-6
In addition to causing bone loss, glucocorticoids appear to lead to changes
in the architectural integrity of bone.7-8
Consequently, more than one fourth of patients treated with long-term glucocorticoid
therapy sustain osteoporotic fractures.9-13
Many treatments have been shown to prevent glucocorticoid-induced osteoporosis.
Calcium and vitamin D (cholecalciferol) should be used by all patients receiving
long-term glucocorticoid therapy and may be sufficient for some, especially
those receiving lower-dose glucocorticoid therapy ( 7.5 mg of prednisone
daily) or those who have normal bone density at the start of therapy.4, 14-15 Hormonal replacement
therapy prevents bone loss and may increase bone density in patients treated
with glucocorticoids.16-17 In
men, testosterone replacement for patients with low testosterone levels results
in increased bone density.18 Calcitonin may
also be helpful in prophylaxis of glucocorticoid-induced osteoporosis, although
some studies show at most a modest benefit over calcium and vitamin D alone.13, 15, 19-22
The strongest data available involve the use of bisphosphonates, including
etidronate, alendronate, and risedronate, which have been shown to maintain
or increase bone density and in some studies decrease fracture risk.14, 23-28
Parathyroid hormone treatment also can reverse glucocorticoid-induced osteoporosis.29
Despite information that glucocorticoid-induced osteoporosis may be
prevented, studies have shown that many patients receiving glucocorticoid
therapy do not receive prophylaxis. In 1 study from England, only 6% of patients
receiving glucocorticoid therapy received calcium supplementation.30 In another study from England, only 14% of patients
received prophylactic medication.31 In a more
recent study from the United States, 58% of patients seen in the outpatient
clinics of an urban teaching hospital received prophylaxis for glucocorticoid-induced
osteoporosis.32 In a telephone survey of patients
receiving long-term glucocorticoid treatment, Buckley et al33
found that 58% of postmenopausal women received preventive treatment while
premenopausal women and men were less likely to be treated.
The objective of the present study was to examine patterns of osteoporosis
prevention in the managed care setting for patients receiving glucocorticoid
therapy. We hypothesized that the patterns of preventive treatment would not
be optimal and that the use of preventive therapies would vary according to
patient age, sex, glucocorticoid dose, and the specialty of the physician
who prescribed glucocorticoid treatment.
SUBJECTS AND METHODS
STUDY SETTING
The Fallon Community Health Plan is a mixed-model health maintenance
organization operating in central and eastern Massachusetts since 1977. The
group-model component of the health maintenance organization (that portion
of the health maintenance organization that contracts with a medical group
for the health care services for members) is composed of a large multispecialty
group practice with more than 200 physicians providing care to approximately
150 000 members. More than 90% of the health plan members are covered
by a drug benefit plan, with a nominal copayment for each prescription. For
members who make out-of-pocket purchases of drugs, prescriptions are favorably
priced at or near the average wholesale price for the agent. Over-the-counter
medications are not covered for any members.
The computerized information system of the health plan contains records
on utilization of all health care services and prescriptions filled, which
are collected as part of routine fiscal activities, as well as the results
of laboratory and radiological studies. Each prescription record contains
a unique patient identification number as well as the medication name, the
date the prescription was filled, the number of tablets dispensed, and the
dose per tablet. Although the use of the automated database allowed us to
confirm that a patient actually filled a prescription, we were not able to
determine if there were instances in which prescriptions were written but
not filled by the patient. Information relating to over-the-counter medications
is not available through the computerized information system.
STUDY POPULATION AND CHARACTERISTICS
The study population was composed of all members of the health plan
in the group-model component. Members included those 20 years and older who
were continuously enrolled between October 1, 1997, and September 30, 1998;
were dispensed at least 1 prescription for an oral glucocorticoid per quarter;
and had confirmation of glucocorticoid use in the medical record. Automated
databases were used to ascertain information about glucocorticoid prescriptions
as well as prescriptions for prophylactic medications. Patients who received
at least 1 dispensing of an oral estrogen, etidronate, alendronate, testosterone,
or intranasal or subcutaneous calcitonin between October 1, 1997, and September
30, 1998, were characterized as having medical treatment for prevention of
glucocorticoid-induced osteoporosis. Medical record review was performed by
trained nurse reviewers, who collected information on the diagnosis requiring
glucocorticoid treatment, prescribing physician specialty, documentation of
patient education concerning calcium and vitamin D supplementation as well
as weight-bearing exercise, and performance of bone mineral density testing
(if done).
The mean prednisone equivalent dose was calculated based on the total
amount of the drug dispensed by the pharmacy from the date of the first prescription
until the last dispensing in the 1-year study period. For patients who were
prescribed methylprednisolone, the prednisone equivalent dose was calculated
at 1.25 mg of prednisone per 1 mg of methylprednisolone.
STATISTICAL ANALYSIS
 2 Tests were used to evaluate differences in proportions.
All tests of significance were 2-tailed and P<.05
was considered significant. To identify factors independently associated with
the use or recommendation of any preventive intervention, we constructed a
multiple logistic regression model. Factors included in the model were the
following: patient age (<75 years vs  75 years); sex (women vs men);
mean daily glucocorticoid dose (5 mg/d vs <5 mg/d); and physician specialty
(rheumatology vs other).
RESULTS
There were 152 818 members of the health plan continuously enrolled
in the group-model component from October 1, 1997, through September 30, 1998.
Of these, 113 401 were 20 years or older. There were 228 patients dispensed
at least 1 oral glucocorticoid prescription per quarter during this period.
Four of these were excluded from the study population (2 had no documentation
of glucocorticoid use in the medical record and the medical records of 2 patients
could not be retrieved). The mean ± SD age of the patients was 70 ±
15 years (Table 1): 29% were younger
than 65 years; 23% were 65 to 74 years; and 48% were 75 years or older. Fifty-seven
percent of the patients were women. The most common diagnoses associated with
the use of glucocorticoid therapy were chronic obstructive pulmonary disease
(26%), asthma (23%), rheumatoid arthritis (22%), and polymyalgia rheumatica
(12%) (Table 1). Some patients
had more than 1 condition that required glucocorticoid treatment. The specialty
of the treating physician is described in Table 1. The mean ± SD daily glucocorticoid dose among the
study subjects was 8.9 ± 7.3 mg of prednisone or equivalent. Seventy
patients (31%) received a mean daily prednisone dose less than 5 mg, 88 (39%)
took 5 to less than 10 mg of prednisone, and 66 (29%) took 10 mg or more of
prednisone daily during the study.
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Table 1. Demographic Characteristics of the Study Population
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The frequencies of medical record documentation of counseling on the
need for calcium and vitamin D supplementation and weight-bearing exercise
are summarized in Table 2. Women
were more likely than men to have received education on the need for calcium
and vitamin D (prevalence odds ratio [OR], 3.58; 95% confidence interval [CI],
1.91-6.75 and OR, 4.05; 95% CI, 2.11-7.83, respectively). The use of bone
mineral testing and pharmacological intervention are also described in Table 2. No patient was prescribed testosterone
during the study period. Women were more likely than men to have bone mineral
density tests (43% vs 15%; prevalence OR, 4.41; 95% CI, 2.17-9.10). Women
were also more likely than men to have at least 1 intervention (76% vs 44%;
prevalence OR, 4.02; 95% CI, 2.19-7.43). When patients were categorized according
to 3 levels of mean daily prednisone dose (<5 mg, 5 to <10 mg, or 10
mg), those taking higher doses of prednisone were found to be less likely
to have received education on vitamin D and exercise (test for trend, P .05). However, there were no differences for education
on calcium, bone mineral density testing, or drug therapy based on glucocorticoid
dose (Figure 1).
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Table 2. Patient Education, Screening, and Treatment for Osteoporosis
of Study Subjects*
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Osteoporosis prevention and treatment of study subjects according
to prednisone dose. Calcium includes education on adequate calcium intake
either via dietary sources or supplements. Vitamin D includes education on
adequate vitamin D intake. Exercise includes recommendations for weight-bearing
exercise. Bone mineral density includes documentation of a bone mineral density
study. Drug includes treatment with hormone replacement therapy, calcitonin,
etidronate, or alendronate. Any intervention includes any person who had at
least 1 of the interventions (this includes calcium or vitamin D education,
exercise recommendations, performance of a bone mineral density study, or
drug therapy).
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Sixty-two (90%) of 69 patients who received glucocorticoid prescriptions
from rheumatologists had at least 1 intervention documented compared with
29 (48%) of 60 for internists, 26 (55%) of 47 for pulmonologists, and 22 (46%)
of 48 for all other specialties (Table 3). Fifty-five patients (25%) were given prescription medications
for osteoporosis. Of these, 25 were prescribed hormone replacement therapy,
14 calcitonin, 6 etidronate, and 17 alendronate, with some patients having
received more than 1 drug during the study period.
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Table 3. Patient Education, Screening, and Treatment for Osteoporosis
of Study Subjects by Specialty of the Prescribing Physician*
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The findings of the multiple logistic regression model that simultaneously
included patient age, sex, mean daily glucocorticoid dose, and physician specialty
suggested that patient sex and physician specialty were independently associated
with the use or recommendation of a preventive therapy. Women receiving long-term
glucocorticoid therapy were significantly more likely to use or receive a
recommendation for a preventive therapy (OR, 3.05; 95% CI, 1.65-5.66). Patients
who were prescribed glucocorticoids by rheumatologists were significantly
more likely to use or receive a recommendation for a preventive therapy compared
with those who were prescribed these agents by physicians in other specialties
(OR, 6.70; 95% CI, 2.78-16.19). After inclusion in the multiple logistic regression
model, patient age and glucocorticoid dose were not found to be significantly
associated with the use of preventive therapy.
COMMENT
While 62% of patients receiving long-term glucocorticoid therapy during
the course of the study year had at least 1 documented intervention aimed
at osteoporosis prevention (counseling on calcium or vitamin D or weight-bearing
exercise; prescription for estrogen, calcitonin, or bisphosphonate; or bone
mineral density study), only 31% had a bone mineral density study, and only
40% had documentation of calcium supplementation and 37% vitamin D supplementation.
Our results for calcium and vitamin D supplementation are similar to the results
of Aagaard et al,32 who found that 42% of patients
received calcium and 37% vitamin D. Of the eligible postmenopausal women in
that study, 57% received hormone replacement therapy, although it could not
be determined if the hormone replacement therapy was prescribed solely for
osteoporosis prophylaxis or for other reasons. Only 20% of the treatment regimens
in the study by Aagaard and coworkers32 were
for bisphosphonate therapy compared with 37% in our study. Given that bisphosphonates
appear to be more effective drugs for prevention of glucocorticoid-induced
osteoporosis, the higher use of bisphosphonates in our population may be the
more appropriate therapeutic approach to this clinical situation.13, 34-35 This higher use of
bisphosphonates may relate to the high levels of insurance coverage for pharmaceuticals
among our population and the increasing awareness of the benefits of this
therapy.
Guidelines for the prevention and treatment of glucocorticoid-induced
osteoporosis have been published by an American College of Rheumatology Task
Force on Osteoporosis Guidelines13 as well
as by a United Kingdom consensus group.35 Clearly
a large number of patients are not receiving intervention for prevention or
treatment according to those guidelines. The reasons for this may include
patient-, physician-, and health care system–related barriers.36-37 As suggested in our study and others,
patient-related factors include sex and postmenopausal state.32, 38
Our study confirms previous reports that women are more likely than men to
receive preventive therapy. Other factors may include the underlying disease
for which the glucocorticoid is prescribed, the severity of illness, comorbidities,
and willingness of the patient to take medication perceived as having a high
frequency of adverse effects (hormone replacement therapy) or as being inconvenient
and expensive (bisphosphonates).
Physician-related barriers likely include a lack of recognition of the
frequency of glucocorticoid-induced osteoporotic fractures or a lack of awareness
of the existence and effectiveness of prophylactic therapy.32, 34
Physicians may be uncertain about which patients require treatment. For example,
the American College of Rheumatology guidelines suggest pharmacological intervention
(in addition to calcium and vitamin D) for patients whose bone density T score
is -1 or lower, while the United Kingdom Consensus Task Force guidelines
recommend treatment for those with a T score less than -1.5.13, 35 Physicians may believe that there
is a safe dose of glucocorticoid, so there may not be a consensus that patients
taking lower doses of prednisone (eg, 7.5 mg) are at risk for osteoporosis.
However, in our study, patients in the higher-dose glucocorticoid therapy
groups were no more likely to receive osteoporosis prophylaxis than patients
in the lower-dose group.
Patients who receive care from rheumatologists are more likely to receive
prophylactic care, suggesting that rheumatologists may be more aware of risks
and treatment options than other physicians.32-33,38
Specialists may have greater access to newer information than generalists.39 As is the case of the American College of Rheumatology
guidelines for the prevention and treatment of glucocorticoid-induced osteoporosis,
such guidelines are often published in journals that target specialists.40 As most of the studies of treatment for osteoporosis
are of women, physicians may not be convinced that prophylaxis for men is
necessary. Some studies have suggested that physicians tend to underprescribe
beneficial prophylactic therapy for the elderly population.41
In addition, physicians focused on treatment of an underlying serious disease
may be less likely to address preventive health care issues.42
Physicians may also be concerned that additional medications may increase
the risk of adverse drug events and decrease patient compliance with essential
therapy.42
Health care system–related barriers may include the cost and availability
(or lack thereof) of bone mineral density testing and the cost of prophylactic
medication, which may be substantial. In our managed care population, that
cost was assumed by the insurer, but in other settings, the cost of prophylaxis
may be the responsibility of the patient or another third party. In addition,
many patients who require glucocorticoid therapy are under the care of 1 or
more specialists with or without a primary care physician, and this fragmentation
of care may result in less use of prophylactic therapy.36
Several strengths and limitations of our study deserve mention. This
study was performed using a managed care database that allowed us to identify
all patients who received prescription medication at the organization's pharmacies.
We did not rely on recorded lists of medication use in the medical record,
which may be discrepant with the medications patients actually take.43 Similarly, while we could not identify patients who
filled their prescriptions at outside pharmacies, we believe that the cost
to the patient of using an outside noncovered pharmacy is such that the pharmacy
records are virtually complete. We did rely on the medical record to determine
use of nonprescription calcium and vitamin D. Physicians may not reliably
document use of nonprescription medications, so our results may be an underestimate
of the use of calcium and vitamin D.44
Another potential limitation concerns the calculation of the glucocorticoid
dose. We calculated the mean daily dose based on the total dose prescribed
during the time from the first to the last prescription in the study period.
Because some patients may have taken their medication intermittently, we may
have underestimated the daily (but not total) dose. We also could not determine
from our study if hormone replacement therapy was prescribed for prevention
of osteoporosis or for other reasons.
In conclusion, while effective regimens for the prevention and treatment
of glucocorticoid-induced osteoporosis exist, many patients do not receive
such treatment. The reasons for this are probably complex, including patient-,
physician-, and health care system–related barriers. Health care organizations
should consider the use of various mechanisms to educate and alert physicians
as to the need for preventive therapy for patients receiving long-term glucocorticoid
therapy. Educational efforts may include the recruitment of local medical
opinion leaders into systematic quality improvement initiatives.45
Efforts to alert physicians to the need for intervention may include the use
of physician prompts to notify the physician that intervention may be needed
for a particular patient.46 Through efforts
aimed at reducing barriers to treatment, the quality of care for patients
receiving long-term glucocorticoid therapy may be improved.
AUTHOR INFORMATION
Accepted for publication October 2, 2000.
Corresponding author and reprints: Robert A. Yood, MD, Division of
Rheumatology, Fallon Clinic, 135 Gold Star Blvd, Worcester, MA 01606.
From the Fallon Clinic, Inc (Drs Yood and Fish, Mr Emani, and Ms Conboy),
Meyers Primary Care Institute, Fallon Healthcare System, and the University
of Massachusetts Medical School (Drs Yood, Harrold, and Gurwitz and Ms Cernieux),
Worcester.
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Adinoff
Pediatrics 2002;110:462-463.
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