Bone Drugs Underused By Oral Steroid Patients


ST. LOUIS — Bisphosphonates remain underutilized in the prevention of glucocorticoid-induced osteoporosis, despite national clinical guidelines that recommend their use in patients on long-term oral steroid therapy, Rosemarie Liu, M.D., said at the annual meeting of the Society of Investigative Dermatology.

“In 2001, the American College of Rheumatology published guidelines recommending that all patients beginning long-term oral steroid therapy of at least 5 mg/day should receive a prescription for a bisphosphonate, if not contraindicated,” said Dr. Liu of Eastern Virginia Medical School, Norfolk. “Despite these guidelines, the vast majority of patients in our study did not receive appropriate prophylaxis for glucocorticoid-induced osteoporosis (GIOP).”

In fact, she said, her study showed that the guidelines had no effect at all on the number of patients who received the bone-protective drugs.

Dr. Liu and her colleagues conducted a cross-sectional study of 35 patients referred to the tertiary dermatology clinic at the Hospital of the University of Pennsylvania, Philadelphia, from 1995 to 2004. Of that group, 60% (21) were female and 83% (29) were white. Their mean age was 54 years (29–86). The mean daily dose of prednisone was 53 mg, with a range of 10–150 mg/day. The patients had been on steroids for a mean of 17 months, with the longest duration of use, 102 months.

Twenty-eight (80%) of the patients were taking prednisone for pemphigus vulgaris; other indications were lupus erythematosus, (4), dermatomyositis (2), and arthritis with interstitial granulomatous dermatitis (1).

The majority of the patients (80%) were not on any bisphosphonates at the time of their referral. The investigators found that the 2001 publication of the ACR Guidelines for Prevention and Treatment of Glucocorticoid-Induced Osteoporosis had no effect on bisphosphonate prescriptions in this group.

“The guidelines were published in July 2001, but we used January 2002 as the cut-off date, because we wanted to give adequate time for them to be incorporated into clinical practice,” Dr. Liu said. Among those referred before 2002, 75% were not on bisphosphonates; among these referred after 2002 (1 year after the guidelines were published), 81% were not on bisphosphonates.

Among the eight patients who were on the drug before referral, seven were taking it specifically for GIOP, and one had been previously diagnosed with osteoporosis.

Dual-energy x-ray absorptiometry scans were available for 18 of the patients. The mean time on steroids before DXA scan was 13 months. Seven of those patients had a normal scan, eight had evidence of osteopenia, and three had evidence of osteoporosis. One patient developed a vertebral fracture within 5 months of beginning prednisone.

“Clinicians should be aware of the ACR guidelines,” Dr. Liu said. “When patients are started on long-term oral steroids, a bisphosphonate should be prescribed unless contraindicated. Also, a baseline DXA scan should be ordered to provide information about baseline bone health, and should be repeated whenever clinically indicated.”

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