Background/Purpose: Glucocorticoids(GC) are frequently used for the treatment of systemic lupus erythematosus (SLE), and glucocorticoid induced osteoporosis (GIOP) is a well-known complication of long term glucocorticoid therapy. American College of Rheumatology (ACR) guidelines recommend vitamin D supplementation for all patients on long term GC, and bisphosphonate therapy – for patients with moderate to high risk of osteoporotic fracture. We aimed to evaluate physicians’ decisions to prescribe vitamin D and bisphosphonates to SLE patients receiving long-term high dose GC, and compare them with the 2017 ACR GIOP guidelines.

Methods: A retrospective cohort of SLE patients who had received care within a large healthcare system in Minnesota between 2011 to 2016 was identified from electronic medical records. Patients receiving prednisone doses of 7.5 mg or higher for at least 90 days were included in the analysis. Demographic data, duration and dosage of GC use, weight, height, previous history of fracture, family history of osteoporosis, smoking and alcohol use were ascertained from medical records, as well as use of vitamin D supplements and bisphosphonates within 6 months of starting high-dose GC therapy. Contraindications to bisphosphonates were also reviewed. Fracture Risk Assessment (FRAX) score was estimated for patients older than 40 years based on chart review. Two clinicians ascertained indication for bisphosphonate through chart review using the 2017 ACR guidelines as a gold standard. A classification tree was used to identify factors that discriminate prescribing bisphosphonates for those 40 and older.

Results: 203 SLE patients met inclusion criteria. Of those, 130 patients were aged 40 years or older. Vitamin D supplement was prescribed to 83% of patients, however, 8.4% were prescribed less than 800 Units per day. Serum vitamin D levels were checked in 30% of patients during high-dose GC therapy, and on average were vitamin D insufficient (median serum vitamin D level 25 [18.5, 30.0]). Thirty-three patients were prescribed a bisphosphonate within 6 months of starting high-dose GC, 32 of them were older than 40. In the older age group, where recommendations for bisphosphonate therapy are available, 25% were prescribed bisphosphonate therapy, compared with 36% who met indications for bisphosphonates per ACR guidelines. A single node was identified in the classification tree. Patients with FRAX scores (for major osteoporotic fracture) of 23.5 or greater were more likely to be prescribed bisphosphonates.

Conclusion: Both vitamin D supplements and bisphosphonates were under prescribed to SLE patients at risk for osteoporotic fracture. Patients were most likely to receive a bisphosphonate prescription if they had a major osteoporotic fracture risk of over 23.5% in 10 years.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/vitamin-d-and-bisphosphonate-therapy-in-sle-patients-who-receive-glucocorticoids-are-we-offering-the-best-care/