Background/Purpose:

American College of Rheumatology (ACR) 2010 guidelines recommend that any patient initiating glucocorticoid therapy with an anticipated duration of ≥3 months should receive a baseline assessment of bone mineral density (BMD), assessment of osteoporosis risk factors, vitamin D supplementation, and counseling on calcium intake and lifestyle modification. Prior studies suggest that implementation of glucocorticoid-induced osteoporosis (GIOP) prevention measures is often suboptimal. Polymyalgia rheumatica (PMR) is a common rheumatologic condition for which most patients receive >3 months of prednisone. As such, we utilized this population to investigate compliance with GIOP prevention measures within our healthcare system’s rheumatology clinics.

Methods:

A retrospective review of the electronic health record (EHR) was conducted to identify patients with a documented diagnosis of PMR and at least 2 rheumatology clinic encounters. A total of 170 patient charts were reviewed. 55 patients met inclusion criteria, which required presence of a new diagnosis of PMR at the time of any rheumatology clinic visit, PMR diagnosis no earlier than November 2010 (date of 2010 ACR GIOP guideline publication), and absence of osteoporosis at the time of PMR diagnosis. The EHR was reviewed directly to obtain data.

Results:

Mean age was 69.5 years, 55% were male, 76% were Caucasian, and mean BMI was 26.9. 64% had a primary care provider within our healthcare system. All patients were treated with ≥3 months of prednisone. Median duration of prednisone use was 20 months (range 4 to 75 months). Median initial dose of prednisone was 20mg/day (range 5 to 80mg/day). Per 2010 ACR guidelines, a baseline dual-energy X-ray absorptiometry (DXA) scan was indicated in all patients. Only 24% of patients had a documented DXA scan between 5 years before and 3 months after PMR diagnosis, although DXA scans obtained outside of our health system may not have been available for review. Among DXA scans ordered within 3 months of diagnosis, 20% were recommended by a rheumatologist, and the rest were ordered by a primary care provider. Recommendations for calcium intake were documented in 42% of patients. Vitamin D supplementation was documented in 55% of patients. Per 2010 ACR guidelines, prophylactic antiresorptive therapy was indicated in at least 96% of patients. However, only 18% were treated with a bisphosphonate at any point after PMR diagnosis. A repeat DXA 1 year or more after PMR diagnosis was obtained in 29% of patients. 20% of these patients developed osteoporosis by T score definition. Although bisphosphonates were indicated at the time of steroid initiation in all patients who developed osteoporosis, none were started on bisphosphonates until 1 year after PMR diagnosis.

Conclusion:

Rates of implementation of GIOP preventative and treatment measures among patients with PMR are suboptimal in our healthcare system. The authors plan to implement an EHR template to remind rheumatology providers to order a DXA and counsel on GIOP prevention. We are also investigating the feasibility of an EHR pop-up to prompt providers to order a baseline DXA when glucocorticoids are ordered for >3 months for patients who do not have a baseline DXA on file.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/adherence-to-american-college-of-rheumatology-guidelines-for-prevention-of-glucocorticoid-induced-osteoporosis-in-patients-with-polymyalgia-rheumatica/