Background/Purpose: Glucocorticoid-induced osteoporosis (GIOP) is a potentially preventable complication in those who are maintained on glucocorticoid (GC) therapy.  It is imperative to identify these patients and initiate osteoporosis (OP) therapy to outweigh the potential harm from GC continuation. As per the ACR guidelines, those on ≥2.5mg/day of GC for ≥90 days should have baseline DEXA at initiation of GC therapy as well as repeat screening every 2-3 years if continued on GC.  For those on >7.5mg/day of GC, the FRAX score should be increased by 1.15 for major osteoporotic fracture and 1.2 for hip fracture.  Those identified as moderate to high risk or on ≥30mg/day of GC with a cumulative dose of >5gm should be started on OP therapy.  We aim to raise awareness of the 2017 ACR guidelines to increase appropriate screening and OP therapy initiation.

Methods: Retrospective chart review of 2,665 patients at 3 outpatient specialty clinics affiliated with the University of South Florida (James A. Haley VA, Tampa General Hospital Health Park, USF Morsani) between April 2018 and November 2019 was performed for baseline data.  Included were those age ≥40 on ≥2.5mg for ≥90 days of GC (n=385).  Excluded were those age < 40, on < 2.5mg/day of GC, on < 90 days of GC, or whose GC was not prescribed by our rheumatology group.  Intervention consisted of educating our providers and having pre-visit chart reviews to identify patients at risk based on the ACR guidelines.  Post-intervention, retrospective chart review of 925 patients was performed between November 2019 and April 2020. Of these, 230 patients met inclusion criteria. Chi-square and Student’s t test were used for comparisons.  Bonferroni correction was used for subgroup comparison. All analyses were conducted using the SAS System.

Results: A total of 385 patients composed the pre-intervention group compared to 230 in the post-intervention.  Of these, 55.6% vs 47.0% were females and 44.4% vs 53.0% were males, respectively. Average age between groups was similar (63.9 vs 64.2). New GC prescription was higher in pre-intervention group (177 vs 56, p< 0.001). Rheumatoid arthritis (RA) was the most common disease between groups (39.7% vs 32.6%). Prednisone was the most prescribed steroid (93.5% vs 93.0%) at a frequent dose of >5mg to < 10mg daily (34.2% vs 33.1%).

Pre-intervention, appropriate DEXA was obtained in 56.9% (n=219) which increased to 68.3% (n=157) in the post-intervention group with an absolute difference of 11.4% (p=0.005).  Overall screening amongst each condition increased, notably in RA (56.9% vs 61.3%) and vasculitis (58.7% vs 73.0%), but this was not statistically significant.  Screening did not increase for those on ≥30mg/day (48.3% vs 48.0%).  Appropriate OP treatment increased post-intervention (30.3% vs 48.1%, p=0.002).  Modifying the FRAX risk score in pre- and post-intervention groups separately upgraded lower risk scores to higher risk (low: 50 to 45 vs 34 to 32; moderate: 69 to 63 vs 31 to 26; high: 70 to 81 vs 55 to 62).

Conclusion: Implementation of the 2017 ACR GIOP guidelines increased DEXA screening and OP therapy initiation in the post-intervention group by improving the identification of high-risk patients.  Abiding by these guidelines will lead to a reduction in further OP complications.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/improving-glucocorticoid-induced-osteoporosis-screening-and-management-in-patients-with-rheumatic-diseases-using-the-2017-acr-guidelines/